OBJECTIVES: To determine whether patients who return to driving after head injury can be considered safe to do so and to compare the patient characteristics of those who return to driving with those who do not. METHODS: In a multicentre qualitative study 10 rehabilitation units collectively registered 563 adults with traumatic brain injury during a 2.5 year period. Recruitment to the study varied from immediately after hospital admission to several years after injury. Patients and their families were interviewed around 3 to 6 months after recruitment. A total of 383 (67.5%) subjects were interviewed within 1 year of injury, of whom 270 (47.6%) were interviewed within 6 months of injury. Main outcome measures were the presence or absence of driving related problems reported by drivers and ex-drivers, and scores on driving related items of the functional independence/functional assessment measure (FIM+FAM). RESULTS: Of the 563 patients 381 were drivers before the injury and 139 had returned to driving at interview. Many current drivers reported problems with behaviour (anger, aggression, irritability; 67 (48.2%)), memory ( 89 (64%)), concentration and attention (39 (28.1%)), and vision (39 (28.1%)). Drivers reported most driving related problems as often as ex-drivers, main exceptions were epilepsy and community mobility. Current drivers scored significantly higher on the FIM+FAM (were more independent), than ex-drivers. The driving group had sustained less severe head injuries than ex-drivers; nevertheless, 78 (56.2%) current drivers had received a severe head injury. Few (61 (16%)) previous drivers reported receiving formal advice about driving after injury. CONCLUSIONS: The existence of problems which could significantly affect driving does not prevent patients returning to driving after traumatic brain injury. Patients should be assessed for both mental and physical status before returning to driving after a head injury, and systems put in place to enable clear and consistent advice to be given to patients about driving. (+info)
Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures.
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OBJECTIVE: To determine whether the evolution of the authors' clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures was associated with improved patient outcome. SUMMARY BACKGROUND DATA: Hemodynamically compromised patients with pelvic fractures present a complex challenge. The multidisciplinary trauma team must control hemorrhage, restore hemodynamics, and rapidly identify and treat associated life-threatening injuries. The authors developed a clinical pathway consisting of five primary elements: immediate trauma attending surgeon's presence in the emergency department, early simultaneous transfusion of blood and coagulation factors, prompt diagnosis and management of associated life-threatening injuries, stabilization of the pelvic girdle, and timely insinuation of pelvic angiography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergency department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the emergency department, and using alternatives to traditional external fixation devices. METHODS: Using trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department. They analyzed patients treated before versus after the May 1998 revision of the clinical pathway. RESULTS: A higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). In the late period, diagnostic peritoneal lavage was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional external fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsanguination (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%). CONCLUSIONS: The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure. (+info)
The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy.
(19/646)
BACKGROUND: There is no disease specific, reliable, and valid clinical measure of Achilles tendinopathy. OBJECTIVE: To develop and test a questionnaire based instrument that would serve as an index of severity of Achilles tendinopathy. METHODS: Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire to assess the severity of Achilles tendinopathy. The final version consisted of eight questions that measured the domains of pain, function in daily living, and sporting activity. Results range from 0 to 100, where 100 represents the perfect score. Its validity and reliability were then tested in a population of non-surgical patients with Achilles tendinopathy (n = 45), presurgical patients with Achilles tendinopathy (n = 14), and two normal control populations (total n = 87). RESULTS: The VISA-A questionnaire had good test-retest (r = 0.93), intrarater (three tests, r = 0.90), and interrater (r = 0.90) reliability as well as good stability when compared one week apart (r = 0.81). The mean (95% confidence interval) VISA-A score in the non-surgical patients was 64 (59-69), in presurgical patients 44 (28-60), and in control subjects it exceeded 96 (94-99). Thus the VISA-A score was higher in non-surgical than presurgical patients (p = 0.02) and higher in control subjects than in both patient populations (p<0.001). CONCLUSIONS: The VISA-A questionnaire is reliable and displayed construct validity when means were compared in patients with a range of severity of Achilles tendinopathy and control subjects. The continuous numerical result of the VISA-A questionnaire has the potential to provide utility in both the clinical setting and research. The test is not designed to be diagnostic. Further studies are needed to determine whether the VISA-A score predicts prognosis. (+info)
Anatomical considerations in the surgical management of blunt thoracic aortic injury.
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PURPOSE: Blunt aortic injury (BAI) involving the thoracic aorta is usually described as occurring at the isthmus. We hypothesized that injuries 1 cm or less from the inferior border of the left subclavian artery (LSCA) are associated with an increased mortality rate compared with injuries that are more distal. METHODS: A retrospective review of patients admitted with the diagnosis of BAI was performed. Injuries were divided into two groups: group I, injuries that were 1 cm or less from the junction of the LSCA and the thoracic aorta; group II, injuries that were more than 1 cm from the LSCA. Primary outcome measures included cross-clamp time, rupture, and death. RESULTS: In a 14-year period, 122 patients were admitted with BAI. The anatomy relative to the LSCA could be determined in 91 patients who underwent operative repair. Forty-two injuries (46%) were classified as group I, and 49 injuries were classified as group II. Group I injuries were characterized by an increased mortality rate (18/42 or 43% in group I vs 11/49 or 22% in group II, P = .04), intraoperative rupture rate (7/42 or 17% in group I vs 1/49 or 2% in group II, P = .003), and cross-clamp time (39.5 +/- 21.9 minutes in group I vs 28.4 +/- 13 minutes in group II, P = .04). Three ruptures occurred while proximal control was being obtained. CONCLUSION: Increased technical difficulty and risk of rupture characterize injuries that occur proximally in the descending thoracic aorta, 1 cm from the LSCA. These injuries may be better managed by instituting bypass before attempting to obtain proximal control and by routinely clamping proximal to the LSCA. (+info)
A survey of sports injuries among a convenience sample of Israeli athletes.
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BACKGROUND: Israel lacks a systematic surveillance of sports injuries, and knowledge of risk factors and specific patterns of injury is inadequate. In order to promote prevention of sports-related injuries, the magnitude of the problem must first be identified and the incidence and severity of sports injuries described. OBJECTIVE: To conduct a survey on previous sports injuries among a sample of Israeli athletes. METHODS: A convenience sample of Israeli amateur athletes participating in the 1997 15th Maccabiah Games was randomly selected. The study group answered an anonymous self-administered questionnaire that included sociodemographic data, and information regarding their sports activity and sports-related injuries that had occurred during the previous 2 years. RESULTS: The study group, aged 12-73 years (median age 21), comprised 301 consenting athletes in 28 different sports. Of these athletes 56.1% reported having had at least one injury. Most injuries (75.6%) involved the upper and lower extremities, and 37.8% of the injured sportsmen had received medical attention from a physician. Half of the athletes participated in contact sports--both collision and limited impact. This group had a much greater proportion of reported injuries in all age groups. CONCLUSION: Surveillance of sports injuries should be expanded in order to develop appropriate prevention programs in Israel. (+info)
Epidemiology of injuries in the Australian Football League, seasons 1997-2000.
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OBJECTIVE: To describe the epidemiology of injuries in the Australian Football League (AFL) over four seasons. METHODS: An injury was defined as "any physical or medical condition that caused a player to miss a match in the regular season." The rationale for this definition was to eliminate a previously noted tendency of team recorders to interpret injury definitions subjectively. Administrative records of injury payments to players who did not play matches determined the occurrence of an injury. RESULTS: The seasonal incidence of new injuries was 39 per club (of 40 players) per season (of 22 matches). The match injury incidence for AFL games was 25.7 injuries per 1000 player hours. The injury prevalence (percentage of players missing through injury in an average week) was 16%. The recurrence rate of injuries was 17%. The most common and prevalent injury was hamstring strain (six injuries per club per season, resulting in 21 missed matches per club per season), followed in prevalence by anterior cruciate ligament and groin injuries. CONCLUSIONS: The injury definition of this study does not produce incidence rates that are complete for all minor injuries. However, the determination of an injury is made by a single entity in exactly the same manner for all teams, which overcomes a significant methodological flaw present in other multiteam injury surveillance systems. (+info)
International trauma care: a comparison between Jerusalem, Israel, and Fairfax County, Virginia, USA.
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BACKGROUND: Trauma is viewed by many as a global problem. The phenomenon of similar outcomes within differing healthcare delivery systems can illuminate the strengths and weaknesses of various trauma systems as well as the effects of these characteristics on patient outcome. OBJECTIVES: To compare and contrast demographic and injury characteristics as well as patient outcomes of two urban/suburban trauma centers, one in Israel and the other in the United States. METHODS: Study data were obtained from the trauma registries of two trauma centers. Demographic variables, injury characteristics and outcomes were compared statistically between registries. RESULTS: Significant differences between the registries were found in demographic variables (age), injury characteristics (Injury Severity Score and mechanism of injury), and outcome (mortality and length of stay). Age and Injury Severity Score were found to be significant predictors of outcome in both registries. The Glasgow Coma Score was found to contribute to patient outcomes more than the ISS. Differences were found in the relative impact of injury and demographic factors on outcomes between the registries. After including the influence of these factors on patient outcomes, significant differences still remained between the outcomes of the trauma centers. CONCLUSIONS: Despite possible explanations for these differences, true comparisons between centers are problematic. (+info)
The effects of alcohol on head injury in the motor vehicle crash victim.
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The objective of this study was to determine if alcohol potentiates the severity of traumatic brain injury (TBI) in motor vehicle crash (MVC) victims, controlling for crash severity characteristics. Prior studies evaluating effects of alcohol on TBI have not accounted for severity of crash. We evaluated severity of head injury by Marshall score [a classification scale of intracranial pathology on head computed axial tomogram (CT)], and blood-alcohol concentration (BAC), while controlling for crash characteristics [traffic accident deformity score (TAD) and belt use]. Marshall scores were determined from initial CT or autopsy reports, by a neurosurgeon, and were categorized into less severe injury (<3) and more severe (> or =3). Logistic regression using this variable as the outcome parameter and crash characteristics, age and BAC as predictors was done, and the odds ratio (OR) and 0.95 confidence interval (0.95 CI) calculated. Fifty-eight patients were analysed: 41% were BAC positive, 30% had a modified Marshall score of > or =3. Patients with positive BAC were 2.1-fold more likely to have a more severe head injury as measured on CT scan by the Marshall scores. We suggest that alcohol potentiates severity of TBI as determined from head CT among MVC victims. Further research will be needed to substantiate this finding as well as to determine its long-term effect on clinical outcome. (+info)