A doubly robust estimation framework to quantify potential bias in linked crash-EMS-trauma data with multi-cohort overlap.

An increasing number of recent studies have suggested that doubly robust estimators with cross-fitting should be used when estimating causal effects with machine learning methods. However, not all existing programs that implement doubly robust estimators support machine learning methods and cross-fitting, or provide estimates on multiplicative scales. To address these needs, we developed AIPW, a software package implementing augmented inverse probability weighting (AIPW) estimation of average causal effects in R (R Foundation for Statistical Computing, Vienna, Austria). Key features of the AIPW package include cross-fitting and flexible covariate adjustment for observational studies and randomized controlled trials (RCTs). In this paper, we use a simulated RCT to illustrate implementation of the AIPW estimator. We also perform a simulation study to evaluate the performance of the AIPW package compared with other doubly robust implementations, including CausalGAM, npcausal, tmle, and tmle3. Our simulation showed that the AIPW package yields performance comparable to that of other programs. Furthermore, we also found that cross-fitting substantively decreases the bias and improves the confidence interval coverage for doubly robust estimators fitted with machine learning algorithms. Our findings suggest that the AIPW package can be a useful tool for estimating average causal effects with machine learning methods in RCTs and observational studies.

Principled methods with which to appropriately analyze missing data have long existed; however, broad implementation of these methods remains challenging. In this and 2 companion papers (Am J Epidemiol. 2018;187(3):576-584 and Am J Epidemiol. 2018;187(3):585-591), we discuss issues pertaining to missing data in the epidemiologic literature. We provide details regarding missing-data mechanisms and nomenclature and encourage the conduct of principled analyses through a detailed comparison of multiple imputation and inverse probability weighting. Data from the Collaborative Perinatal Project, a multisite US study conducted from 1959 to 1974, are used to create a masked data-analytical challenge with missing data induced by known mechanisms. We illustrate the deleterious effects of missing data with naive methods and show how principled methods can sometimes mitigate such effects. For example, when data were missing at random, naive methods showed a spurious protective effect of smoking on the risk of spontaneous abortion (odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.19, 0.93), while implementation of principled methods multiple imputation (OR = 1.30, 95% CI: 0.95, 1.77) or augmented inverse probability weighting (OR = 1.40, 95% CI: 1.00, 1.97) provided estimates closer to the "true" full-data effect (OR = 1.31, 95% CI: 1.05, 1.64). We call for greater acknowledgement of and attention to missing data and for the broad use of principled missing-data methods in epidemiologic research.

We propose a new inverse probability weighting (IPW) estimator for moment condition models with missing data. Our estimator is easy to implement and compares favorably with existing IPW estimators, including augmented inverse probability weighting (AIPW) estimators, in terms of efficiency, robustness, and higher order bias. We illustrate our method with a study of the relationship between early Black-White differences in cognitive achievement and subsequent differences in adult earnings. In our dataset the early childhood achievement measure, the main regressor of interest, is missing for many units.

We develop a novel doubly-robust (DR) imputation framework for longitudinal studies with monotone dropout, motivated by the informative dropout that is common in FDA-regulated trials for Alzheimer's disease. In this approach, the missing data are first imputed using a doubly-robust augmented inverse probability weighting (AIPW) estimator, then the imputed completed data are substituted into a full-data estimating equation, and the estimate is obtained using standard software. The imputed completed data may be inspected and compared to the observed data, and standard model diagnostics are available. The same imputed completed data can be used for several different estimands, such as subgroup analyses in a clinical trial, allowing for reduced computation and increased consistency across analyses. We present two specific DR imputation estimators, AIPW-I and AIPW-S, study their theoretical properties, and investigate their performance by simulation. AIPW-S has substantially reduced computational burden compared to many other DR estimators, at the cost of some loss of efficiency and the requirement of stronger assumptions. Simulation studies support the theoretical properties and good performance of the DR imputation framework. Importantly, we demonstrate their ability to address time-varying covariates, such as a time by treatment interaction. We illustrate using data from a large randomized Phase III trial investigating the effect of donepezil in Alzheimer's disease, from the Alzheimer's Disease Cooperative Study (ADCS) group.

PurposeThe authors assessed the certification of street food retailers in Ghana in terms of awareness, training, willingness to be certified, determinants, agreement with certification requirements and impacts on performance.Design/methodology/approachPrimary data was sourced from 200 street food retailers. Descriptive statistics, Likert scale, mean comparison test, heteroskedastic probit, inverse-probability-weighted regression adjustment (IPWRA), inverse probability weights (IPW) and augmented inverse-probability weighting (AIPW) were applied.FindingsMost uncertified retailers were willing to be certified. Awareness about certification was high. Most of the certified retailers had been trained on certification, while most uncertified retailers had not been trained. Being a female, being educated, being a migrant vendor, possessing experience in retailing, training in certification, trust in the local certification process, the amount spent in preparing food and the number of customers are crucial variables that increase the probability of being certified among street food vendors. Street food retailers agreed to all the requirements for certification. Certification boosts the performance of street food retailers in terms of the number of customers and contracts received. Training on certification is recommended for street food retailers.Research limitations/implicationsThe limitation of this study is mainly due to the type of food retailers selected. Street food vending in Ghana is done among those who cook food for selling, those who sell processed products such as drinks and those who sell vegetables and other uncooked agriproducts. Meanwhile, the authors selected unorganised retailers who primarily cook local and regional dishes for sale in this study. Thus, the study did not include organised food retailers such as restaurants. Therefore, generalising the study results for street food vendors should be made with caution.Originality/valueSeveral studies have been conducted on street food retailing across the globe on knowledge of food-safety practices, risk practices, bacterial contamination of street retailing food, toxicological hazards of street foods and compliance with technical and hygienic requirements by street food retailers, among others. However, empirical studies on the certification/licensing of street food retailers and its impact have been given little attention. As a result, this study investigates the certification of street food retailers and its impacts on retailers' performance in Ghana.

INTRODUCTION Pelvic ring fractures (PRFs) are uncommon injuries with a prevalence of 23–34 per 100,000 population. Pelvic ring fractures are commonly found in polytrauma patients who have been involved in high-energy injuries, such as fall from height and road traffic accidents, typically in the young and productive age group. As such, PRF is associated with a high mortality rate, with mortality reported to be up to 37% in our local population. In recent times, advances in management algorithms have maximised patient survival and outcomes following severe PRFs. Yet, it is important to note that PRF also results in significant morbidity, as these patients often sustain other severe injuries, such as associated vascular, neurological and urological injuries. Importantly, these patients are economically active and despite a prolonged period of rehabilitation, they can still be impaired in the ability to return to work (RTW). The primary aim of our study was to describe the rate and time to RTW after surgical fixation of PRF in our local population, while the secondary aim was to identify factors that influence the ability to RTW and the ability to return to the same job scope after surgical fixation of PRFs. METHODS This is a retrospective cohort study conducted at a single institution in Singapore. All patients with surgically treated PRFs were identified. The review of medical records was approved by our local ethical committee (DSRB 2019/00263). Between 1 October 2010 and 30 November 2017, there were 42 patients who had surgical fixation of PRFs in our institution. Exclusion criteria were patients who died perioperatively, who were lost to follow-up or who had incomplete data. As such, a total of 26 patients were included in our final data analysis. We acquired the following information from the patient medical records: data on demographics, comorbidities, type of pelvic fractures according to the Tile system of classification, American Society of Anesthesiologists' (ASA) physical status classification, high dependency/intensive care unit (HD/ICU) admission, injury severity score (ISS), other concomitant injuries, fracture management (anterior element, posterior element, or anterior and posterior element fixation), complications, preinjury work status, follow-up time and RTW characteristics.[1-3] Complications of PRF were defined as infection (related to pelvic fracture fixation), neurological injuries, chronic pelvic pain and vascular injuries. The preinjury health status was classified as morbid for ASA scores >1. Polytrauma was defined as an ISS score of >15 on hospital admission.[4] Continuous data is presented as mean and standard deviation (SD), while categorical data is presented as frequency and percentages. Patients were taken as having RTW if they managed to return to any form of work. Statistical analysis was performed with Fisher's exact test for categorical outcomes and Student's t test or Mann–Whitney test for continuous outcomes. Kolmogorov–Smirnov test was used to determine whether the data were normally distributed. Statistical analysis of the data was conducted with IBM SPSS Statistics version 23 (IBM Corp, Armonk, NY, USA). A P value of 0.05 was considered to be statistically significant. RESULTS The average age of the 26 patients was 36 ± 12 (range 21–62) years at the time of the accident, and they consisted of an equal number of males and females. The mean duration of follow-up was 14 (range 3.2–41.6) months. Table 1 shows the demographics of our patients. All our patients were involved in high-energy trauma. The majority of patients (53.8%) were involved in road traffic accidents. Four (15.4%) patients were involved in workplace accidents.Table 1: Demographics of patients (N=26).None of the patients had preinjury disability. Ten (38.5%) patients had preexisting comorbidities before PRF, of which five (19.2%) patients had previous and existing psychiatric history (one patient had major depressive disorder who defaulted medications, two patients had adjustment disorder and one of them had previous suicide attempts, one patient had schizophrenia with previous suicide attempt and one patient had previous acute situational reaction). Of the remaining patients with comorbidities, there were two (7.7%) patients with hypertension, one (3.8%) patient with diabetes mellitus, one (3.8%) patient with hyperthyroidism and one (3.8%) patient with asthma. None of the patients had previous PRF, and none of the patients with previous suicide attempts had serious injuries. One patient was pregnant and was at 4 weeks of gestation. Most patients (n = 15, 57.7%) sustained a Tile C PRF, while 10 (38.5%) patients sustained a Tile B PRF and one (3.8%) patient sustained a Tile A PRF. In terms of the type of fixation, 16 (61.5%) patients had anterior element fixation only, four (15.4%) patients had posterior element fixation only and six (23.1%) patients had both anterior and posterior element fixation [Figure 1]. Open fractures were seen in three (11.5%) patients, of which two patients were Grade 2 and one patient was Grade 3A on the Gustilo–Anderson scale.[5] The time to definitive fixation was 5.8 ± 5.1 days, and the length of ICU or HD stay was 8.4 ± 6.3 days in 20 (76.9%) patients who required ICU or HD admission. Other clinical characteristics are shown in Table 2.Figure 1: (a) Radiograph of the pelvis shows initial stabilisation of a pelvic ring fracture. (b) Image intensifier radiograph of the pelvis shows definitive fixation of both the anterior and posterior elements.Table 2: Clinical characteristics of the patients (N=26).Concomitant injuries were identified in 24 (92.3%) patients, of which the majority had injuries to the extremities and the viscera. There were 17 (65.4%) patients who had injuries to the extremities, while 21 (80.8%) patients had visceral injuries. Ten (38.5%) patients had spine injuries, of which four patients required spinal stabilisation. Neurological injury was observed in three (11.5%) patients, with two (7.7%) patients suffering from focal neurological deficits (sciatic nerve compression with resultant foot drop) and one (3.8%) patient exhibiting complete lower limb paralysis due to spinal cord injury. Also, 38.5% of our patients developed postoperative complications. Two (7.7%) patients developed sonographically proven lower limb deep vein thrombosis and two (7.7%) patients developed surgical site infection treated conservatively (both developed superficial wound infections). One (3.8%) patient developed left hip septic arthritis, requiring debridement and removal of implants, and necessitating long-term antibiotics, complicated by avascular necrosis that required total hip replacement. Five (19.2%) patients developed chronic pelvic pain. There was no documented development of neurological complications postoperatively. Twenty-one (80.8%) patients were employed before injury, with one patient finding employment after PRF. As such, we included a total of 22 patients for our RTW analysis. In total, 15 (68.2%) patients were able to RTW, of which seven (46.7%) patients returned to the same job and same duties, two (13.3%) patients returned to the same job and light duties, and six (40.0%) returned to work with a new job. Two students (considered unemployed patients) who sustained PRF were able to return to school. Of the patients who were unable to RTW, five (22.7%) patients retired, while two (9.1%) patients were workmen compensation patients who returned to their resident countries after claiming workmen compensation. The average time to RTW was 12.5 (range 3–34.5) months. Return to work rates were 9.1% at 3 months, 31.9% at 6 months, 54.5% at 12 months and 59.1% at 24 months. Of those who RTW, the proportion of patients returning to preinjury workplace was 40% at 6 months, 60% at 12 months and 24 months. Analysis of factors related to RTW and RTW to the same job and duties did not reveal any statistically significant association. The factors analysed were gender, age at surgery, length of hospitalisation, time to definitive surgery, ISS score, ASA score, ICU/HD admission and sedentary job. DISCUSSION It is known that PRFs after high-energy trauma are associated with a lower quality of life and are a leading cause of disability affecting recovery and RTW.[6] For example, Bott et al.[7] reported the long-term functional outcomes in patients with surgically treated pelvic fractures, with an average follow-up duration of 15 years. Their study demonstrated that patients have long-term physical functional limitations. Consistent with previous studies, most of our patients with PRF were of young and productive age group (average age 36.3 years) and all patients were involved in high-energy accidents, the majority being patients involved in road traffic accidents.[6,8] It is important to identify the time to RTW of patients and the type of work patients return to, which plays a role in understanding the impact of PRF in our local population as PRF can result in a large socioeconomic burden to the society. Many studies have described the rate of RTW, the impact of these injuries on the earning capacity and factors related to RTW after PRF.[9-16] Yet, to the best of our knowledge, there have been only three studies that demonstrate the exact time of RTW after PRF, none of which is based on an Asian population.[10,11,16] Previous studies have reported RTW rates for surgically treated PRF to range from 57% to 84%.[9,10,12,16,17] Our population showed similar results, where 68.2% of the patients returned to work. We also found that 60% were able to work in the same workplace, with 46.7% returning to the same job and duties and 13.3% returning to a limited job scope. On the other hand, 40% changed jobs, which may have resulted in further productivity loss and loss of earning capacity as these patients may have required retraining. We found that the mean time of RTW was 12.5 months. In comparison, Aprato et al.[10] reported a mean time of 195 days in 50 patients, Madhu et al.[16] reported a mean time of 9.4 months in an isolated pelvic injury group of 17 patients who returned to the previous level of employment, while Schäffler et al.[11] reported a mean time of 9.5 months in 58 patients. Importantly, the time to RTW was at least 25% longer in our population and we postulate that several reasons could account for this. Firstly, the higher ISS scores in our population could have contributed to the prolonged RTW. Sixty percent of our patients (those who returned to work) had a higher ISS score (ISS >15), compared to 28% reported by Aprato et al.[10] Similarly, Madhu et al.[16] reported a median ISS score of 19 compared to our mean of 21. ISS has been identified to be a strong prognostic factor of RTW.[10,12,16] Furthermore, in Singapore, the concept of an RTW coordinator model of care in facilitating RTW for injured workers is still in its infancy, although this has long been implemented in multiple western countries.[18,19] The RTW decision is still frequently based upon the surgeon's medical opinion, although surgeons often have limited understanding of the patient's work environment and work demands to determine the impact of injury on the ability to work. As a result, medical leave may have been given until patients completely recovered from their initial injury.[20,21] We also sought to evaluate predictors of RTW. Although no factors were found to be significantly associated with RTW in our study population, previous studies have demonstrated that the ISS score, rather than the type of fracture sustained, is a strong predictor for RTW.[10,12] These are important factors to note. In terms of economic costs, the higher the severity of the injury, the higher the hospitalisation costs are likely to be due to admission to ICU and other injury-related treatment costs. For example, in our study population, the average hospitalisation cost was SGD$60,100 ± 42,756 (range 13,509–187,092). This compounds the economic burden that patients already face with prolonged RTW and occupational changes. Also, severe pelvic fracture patients are often multiple trauma cases.[22–24] Patients may sustain disabilities from other injuries, affecting the ability to RTW. Moreover, 92.3% of our patients had concomitant injuries, where importantly, 26.9% sustained severe head injuries and 15.4% required spinal stabilisation for spine injuries. These highlight the importance of starting rehabilitation and work reintegration strategies early in PRF patients' recovery. Our study has several limitations. Firstly, there is a possible selection bias, as this study did not include patients who have transferred hospital for further care and these patients may have sustained more severe injuries. Return to work rates may have been lower. Time to RTW may have been even more prolonged compared to our study population. Secondly, our study had a small sample size, although all patients who had surgical fixation of PRF at our institution between 1 October 2010 and 30 November 2017 were included in this study. This limits the conclusions drawn from this study, especially in terms of factors associated with RTW. Thirdly, there may be information bias due to the retrospective study design of this paper. Lastly, our study also did not examine the earnings and the recovery of these patients in terms of functional outcomes, which would be helpful in demonstrating the true impact of PRF in our local population. Further studies with a prospective design, larger samples and functional scoring will be useful. In conclusion, PRF occurs in the economically active age group, and 68.2% of patients are able to RTW in our local population. There is a socioeconomic burden in these patients, and RTW strategies should be designed and applied in these patients to help them with work reintegration after injury. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Impact of Dental Referral Prior to Elective Surgery on Postoperative Outcomes.

Patients that suffer from severe multiple trauma are highly vulnerable to the development of complications that influence their outcomes. Therefore, this study aimed to evaluate the risk factors that can facilitate an early recognition of adult patients at risk. The inclusion criteria were as follows: admission to a level 1 trauma center, injury severity score (ISS) ≥ 16 (severe injury was defined by an abbreviated injury score (AIS) ≥ 3) and ≥18 years of age. Injury- and patient-associated factors were correlated with the development of four complication clusters (surgery-related, infection, thromboembolic events and organ failure) and three mortality time points (immediate (6 h after admission), early (>6 h–72 h) and late (>72 h) mortality). Statistical analysis was performed using a Chi-square, Mann–Whitney U test, Cox hazard regression analysis and binominal logistic regression analysis. In total, 383 patients with a median ISS of 24 (interquartile range (IQR) 17–27) were included. The overall mortality rate (27.4%) peaked in the early mortality group. Lactate on admission significantly correlated with immediate and early mortality. Late mortality was significantly influenced by severe head injuries in patients with a moderate ISS (ISS 16–24). In patients with a high ISS (≥25), late mortality was influenced by a higher ISS, older age and higher rates of organ failure. Complications were observed in 47.5% of all patients, with infections being seen most often. The development of complications was significantly influenced by severe extremity injuries, the duration of mechanical ventilation and length of ICU stay. Infection remains the predominant posttraumatic complication. While immediate and early mortality is mainly influenced by the severity of the initial trauma, the rates of severe head injuries influence late mortality in moderate trauma severity, while organ failure remains a relevant factor in patients with a high injury severity.

As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30. Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

Acute work-related trauma is a leading cause of death and disability among US workers. The research objectives were to assess: (1) the feasibility of estimating Abbreviated Injury Scale-based injury severity scores (ISS) from ICD-9-CM codes available in workers' compensation (WC) medical billing data, (2) whether ISS predicts work-related disability and medical cost outcomes, (3) whether ISS adds value over other injury severity proxies, and (4) whether the utility of ISS differs for an all-injury sample compared with three specific injury samples (amputations, extremity fractures, traumatic brain injury). ISS was estimated from ICD-9-CM codes using Stata's user-written -icdpic- program for 208,522 compensable nonfatal WC claims for workers injured in Washington State from 1998 to 2008. The Akaike Information Criterion and R(2) were used to compare severity measures. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modeled using linear regression. Work disability and medical costs increased monotonically with injury severity. For a subset of 4,301 claims linked to the Washington State Trauma Registry (WTR), there was moderate agreement between WC-based ISS and WTR-based ISS. Including ISS together with an early hospitalization indicator resulted in the most informative models; however, early hospitalization is a more downstream measure. ISS was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity should be considered as a potential confounder for occupational injury intervention, program evaluation, or outcome studies, and can be estimated using existing software when ICD-9-CM codes are available.

ABSTRACTBackgroundThe Injury Severity Score (ISS) is a commonly used trauma assessment tool. An accurately calculated ISS is fundamental when used for the classification of the injury severity of trauma patients and subsequent evaluation of a trauma center's performance. This study aimed to analyze the accuracy of a preliminary ISS of trauma patients in the resuscitation room.MethodsA preliminary ISS assessed by clinicians during the primary assessment of trauma patients at the Trauma Center of Rigshospitalet, Denmark in the time period January 2019–May 2024 was recorded in a trauma database and compared with definitive ISS assessed by certified Abbreviated Injury Scale (AIS) coders. Clinicians were not AIS‐certified. All trauma patients were clinically assessed by a trauma team. The primary outcome of the study was the interrater agreement of the preliminary and definitive ISS, evaluated using Cohen's Kappa and a Bland–Altman plot for visual representation. Cases with missing or invalid data were excluded.ResultsIn total, 3623 trauma patients with preliminary and definitive ISS were registered. The majority of trauma patients were adult 2858 (79%), and male 2433 (67%). Penetrating trauma was sustained by 588 (16%) patients while 3032 (84%) suffered blunt trauma. The Cohen's Kappa between the preliminary and the definitive ISS value was 0.51 (95% CI 0.50–0.53), suggesting a moderate overall agreement. The lowest agreement was found in the subgroup of seriously (ISS 15–24) injured patients, 0.31 (95% CI 0.27–0.35). The Bland–Altman plot showed acceptable agreement, although it seemed there was an increasing difference in ISS with increasing mean ISS. No indication of other bias or systematic mistakes was identified.ConclusionThis study found a moderate but overall acceptable level of agreement between preliminary and definitive ISS in trauma patients. In the most severe cases, the preliminary ISS showed a tendency to underestimate injury severity. These findings suggest that the accuracy of preliminary ISS diminishes in cases of severe trauma, highlighting the need for cautious interpretation in critically injured patients. Preliminary ISS remains a valuable tool in clinical settings for trauma severity classification.

Review the association between injury severity, narrowing of the spinal canal, and neurologic deficit in thoracolumbar burst fractures. To determine which variable has a stronger association with neurologic deficit: spinal canal compromise or injury severity. Literature has not reached a consensus regarding the cause of neurologic deficits in these fractures. Some believe it to be the spinal canal compromise and others the energy of trauma. A review of the clinical data and axial computerized tomography of 184 patients was performed. The injury severity was determined by subtracting neurologic data from the Injury Severity Score and New Injury Severity Score (ISSM and NISSM) to avoid the bias of overestimating neurologic lesions. Patients with neurologic deficit presented higher canal compromise (52% vs. 34%), higher Injury Severity Score (24 vs. 11), New Injury Severity Score (26 vs. 13), ISSM (10 vs. 7), and NISSM (11 vs. 8, respectively). A positive correlation was found among these scores and the spinal canal compromise (P < 0.005; r < 0.35). In the current methodology, logistic regression proved narrowing of the spinal canal to be the only independent variable associated with neurologic deficit. Narrowing of the spinal canal has a stronger association with neurologic deficit than injury severity in thoracolumbar burst fractures.

The Injury Severity Score (ISS) is widely used in trauma research worldwide. An ISS cutoff value of ≥16 is frequently used as the definition of severe injury in Japan. The mortality of patients with ISS ≥16 has decreased in recent years, owing to the developing the trauma care system. This study aimed to analyze the prevalence, in-hospital mortality, and odds ratio (OR) for mortality in Japanese injured patients by age, injury mechanism, injury region, and injury severity over 10 years. This study used the Japan Trauma Data Bank (JTDB) dataset, which included 315,614 patients registered between 2009 and 2018. 209,290 injured patients were utilized. This study evaluated 10-year trends of the prevalence and in-hospital mortality and risk factors associated with in-hospital mortality. The overall in-hospital mortality was 10.5%. During the 10-year study period in Japan, the mortality trend among all injured patient groups with ISS 0–15, 16–25, and ≥26 showed significant decreases (p <0.001). Moreover, the mortality risk of patients with ISS ≥26 was significantly higher than that of patients with ISS 0–15 and 16–25 (p <0.001, OR = 0.05 and p<0.001, OR = 0.22). If we define injured patients who are expected to have a mortality rate of 20% or more as severely injured, it may be necessary to change the injury severity definition according to reduction of trauma mortality as ISS cutoff values to ≥26 instead of ≥16. From 2009 to 2018, the in-hospital mortality trend among all injured patient groups with ISS 0–15, 16–25, and ≥26 showed significant decreases in Japan. Differences were noted in mortality trends and risks according to anatomical injury severity.

Aims, Objectives and BackgroundFemale patients are consistently outnumbered by males in trauma studies. This introduces bias towards male physiology when developing treatments and protocols and may result in females receiving...

Overtriage in the trauma resuscitation room (TRR) is often a consequence of admission based solely on trauma mechanism criteria. As interleukin-6 (IL-6) can assess injury severity in critically injured patients, the hypothesis of this study was that IL-6 can differentiate upon admission between mild (Injury Severity Score (ISS) 0-8) and moderate (ISS 9-15) trauma and that the parameter correlates with injury severity in lower injury severity groups (ISS < 16) during the first 24h. Subsequently, we evaluated the ability to define IL-6 cut-off values with an adequate sensitivity, specificity, and negative predictive value to distinguish between moderate and mild injuries. Fifty patients admitted to the TRR solely based on trauma mechanism criteria and with an ISS < 16 were included in the study. IL-6 was measured at admission, 1, 6, 12 and 24h later. Thirty-one patients were mildly injured (ISS 0-8), while nineteen patients sustained moderate injuries (ISS 9-15). IL-6 correlated significantly with ISS at all time points. Moderately injured patients showed significantly higher IL-6 levels than mildly injured patients during the first 6h. IL-6 levels at admission predicted moderate injuries for the IL-6 cut-off value of 2.9pg/ml with a sensitivity of 0.933, specificity of 0.370 and a negative predictive value of 0.970 resulting in undertriage rates of 6.6% and overtriage rates of 54.8%. The data of this feasibility study indicates that IL-6 has the potential to be employed in clinical workflows for early determination between patients with mild and moderate injuries, who are admitted to TRR based on trauma mechanism criteria to abort as early as possible TRR treatment and therefore free resources immediately while preserving patients' safety.