Disseminated peritoneal leiomyomatosis mimicking carcinomatosis: A case report.

INTRODUCTION AND IMPORTANCE: Disseminated Peritoneal Leiomyomatosis (DPL) is a rare benign proliferation of solid peritoneal lesions along the abdominopelvic cavity comprised of smooth muscle and connective tissue. Though hormonal and iatrogenic causes have been theorized, the exact etiology remains unknown. Most patients with DPL are frequently premenopausal with a history of myomectomy or prior hysterectomy. These patients can present asymptomatically or with abnormal uterine bleeding and abdominal discomfort. DPL is a rare entity with less than 150 cases reported in the literature, showcasing the need of awareness of this poorly understood neoplasm. Imaging, if performed, is helpful as positron emission tomography (PET) can differentiate DPL from malignant peritoneal disease. Treatment involves medical and surgical options based on patient's clinical presentation, with medical treatment with gonadotropin-releasing hormone agonist being first line. CASE PRESENTATION: We report a case of a previously healthy female presenting for desired laparoscopic tubal ligation with incidental countless peritoneal nodules suspicious for carcinomatosis found during the operative event but proven leiomyomas after histologic examination. CLINICAL DISCUSSION: Differentiating DPL from mimickers such as leiomyosarcoma, endometriosis, and carcinomatosis remains a challenge as macroscopic appearances are similar ultimately requiring histology evaluation. CONCLUSION: Awareness of the entity is crucial to avoid misdiagnosis and unnecessary anxiety associated with a presumptive diagnosis of malignancy for a largely benign entity.

Genetic Dissection of BDNF and TrkB Expression in Glial Cells.

The brain-derived neurotrophic factor (BDNF) and its high-affinity receptor tropomyosin-related kinase receptor B (TrkB) are widely expressed in the central nervous system. It is well documented that neurons express BDNF and full-length TrkB (TrkB.FL) as well as a lower level of truncated TrkB (TrkB.T). However, there are conflicting reports regarding the expression of BDNF and TrkB in glial cells, particularly microglia. In this study, we employed a sensitive and reliable genetic method to characterize the expression of BDNF and TrkB in glial cells in the mouse brain. We utilized three Cre mouse strains in which Cre recombinase is expressed in the same cells as BDNF, TrkB.FL, or all TrkB isoforms, and crossed them to Cre-dependent reporter mice to label BDNF- or TrkB-expressing cells with soma-localized EGFP. We performed immunohistochemistry with glial cell markers to examine the expression of BDNF and TrkB in microglia, astrocytes, and oligodendrocytes. Surprisingly, we found no BDNF- or TrkB-expressing microglia in examined CNS regions, including the somatomotor cortex, hippocampal CA1, and spinal cord. Consistent with previous studies, most astrocytes only express TrkB.T in the hippocampus of adult brains. Moreover, there are a small number of astrocytes and oligodendrocytes that express BDNF in the hippocampus, the function of which is to be determined. We also found that oligodendrocyte precursor cells, but not mature oligodendrocytes, express both TrkB.FL and TrkB.T in the hippocampus of adult mice. These results not only clarify the expression of BDNF and TrkB in glial cells but also open opportunities to investigate previously unidentified roles of BDNF and TrkB in astrocytes and oligodendrocytes.

Conversion of Elbow Arthrodesis to Total Elbow Arthroplasty: A Case Report and Literature Review.

Elbow arthrodesis is a salvage operation designed to relieve pain and enable weight bearing in young patients with painful arthritic joints who have failed all other treatment modalities. Unfortunately, elbow arthrodesis is poorly tolerated by many patients because there is no fusion position that accommodates all activities of daily living. As indications for elbow arthroplasty expand and implant design improves, patients living with elbow arthrodesis may seek conversion to arthroplasty to regain a functional range of motion. Only one case of elbow arthrodesis to elbow arthroplasty conversion has been reported in the English literature to date. We present the case of a 58 year old male, five years status post elbow arthrodesis, unable to perform his ADLs adequately, who was successfully converted to a total elbow arthroplasty. Indications, contraindications, and technical pearls are discussed.

Effect of Smoking on Short-term Postoperative Complications After Elective Upper Extremity Surgery.

Background: There is a paucity of literature exploring the impact of smoking on short-term complications, readmissions, and reoperations after elective upper extremity surgery using a large multicenter national database. We hypothesized that smokers will have an increased rate of complications, readmissions, and reoperations compared with a cohort of nonsmokers undergoing elective upper extremity surgery. Methods: Patient data were collected from the American College of Surgeons National Surgical Quality Improvement Program database between the years 2012 and 2017. Patients were included if they underwent elective surgery of the upper extremity using 338 predetermined Current Procedural Terminology codes. The data collected were divided into patient demographics, comorbidities, perioperative variables, and 30-day complications. Current smoking status was defined as smoking within 1 year prior to surgery. The incidence of surgical complications, reoperations, and readmissions was compared between the 2 cohorts using multivariable regression analysis. Results: Of the 107 943 patients undergoing elective surgeries of the upper extremity, 73 806 met the inclusion criteria. Of these, 57 986 (78.6%) were nonsmokers in the year prior to surgery, and 15 820 (21.4%) were current smokers. Between these groups, current smokers were younger (P < .001), more often men (P < .001), had lower body mass index (P < .001), and more often underwent procedures that involved bone manipulation (P < .001). Multivariate regression analysis defined current smoking as significantly associated with overall surgical site complications, superficial surgical site infections, deep surgical site infections, reoperation, and readmission. Conclusion: Current smoking was significantly associated with an increase in all surgical site complications, readmissions, and reoperations after elective upper extremity surgery. Surgeons should consider smoking a modifiable risk factor for postoperative complications and appropriately counsel patients on outcomes and complications given the elective nature of upper extremity surgery.

Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations.

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

Effect of DS-8500a, a Novel G Protein-Coupled Receptor 119 Agonist, on the Pharmacokinetics of Rosuvastatin and Atorvastatin in Healthy Subjects.

BACKGROUND: Non-clinical study data suggest that DS-8500a, a G protein-coupled receptor 119 agonist, exhibits antidiabetic activity, inhibition of some transporters and induction of cytochrome P450 (CYP) 3A. Statins are substrates for some transporters and CYP3A that may be coadministered with DS-8500a in clinical practice. OBJECTIVE: To determine the potential effects of DS-8500a on the pharmacokinetics of statins, we evaluated the effects of repeated oral administration of DS-8500a 75 mg on the pharmacokinetics of rosuvastatin and atorvastatin in healthy adults. METHODS: We performed two single-center, open-label, single-sequence studies. In Study I, subjects received single-dose rosuvastatin 10 mg (Period A) and DS-8500a 75 mg once daily + single-dose rosuvastatin 10 mg (Period B). In Study II, subjects received single-dose atorvastatin 10 mg (Period A) and DS-8500a 75 mg once daily + single-dose atorvastatin 10 mg (Period B). Primary pharmacokinetic endpoints were maximum plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC) of rosuvastatin and atorvastatin. Safety was evaluated. RESULTS: In Study I, the Cmax and AUC of rosuvastatin increased by 66% and 33%, respectively, when coadministered with DS-8500a, versus rosuvastatin alone. In Study II, the Cmax of atorvastatin increased by 28%, but AUC remained unchanged following coadministration with DS-8500a, versus atorvastatin alone. Treatment-emergent adverse events were mild to moderate and mostly unrelated to the study drugs. CONCLUSIONS: Multiple doses of DS-8500a increased exposure to rosuvastatin and atorvastatin. This short-term study suggests that the impact of DS-8500a coadministration on atorvastatin exposure is limited and may not be clinically relevant. Nevertheless, caution may be necessary when patients are coadministered rosuvastatin with DS-8500a. CLINICALTRIALS. GOV IDENTIFIER: NCT03699774. JAPAN PHARMACEUTICAL INFORMATION CENTER IDENTIFIER: JapicCTI-152878.

Effects of Comfort Education on Maternal Comfort and Labor Pain.

The effects of providing education regarding comfort options available in the hospital setting on level of maternal comfort and pain during labor were explored in a quasi-experimental pretest/posttest comparison group design (N = 80). No significant difference was found in maternal comfort or pain between the intervention group that received comfort education and the control group. Comfort education did result in change for plans to maintain comfort during labor (p = .000), an increased use of comfort measures during labor (p = .000), and an increased probability of continuation with original plans for pain control during labor. Providing education for maintaining comfort during labor can allow women to make informed choices during labor.

Maryland's Helicopter Emergency Medical Services Experience From 2001 to 2011: System Improvements and Patients' Outcomes.

STUDY OBJECTIVE: Helicopter emergency medical services (EMS) has become a well-established component of modern trauma systems. It is an expensive, limited resource with potential safety concerns. Helicopter EMS activation criteria intended to increase efficiency and reduce inappropriate use remain elusive and difficult to measure. This study evaluates the effect of statewide field trauma triage changes on helicopter EMS use and patient outcomes. METHODS: Data were extracted from the helicopter EMS computer-aided dispatch database for in-state scene flights and from the state Trauma Registry for all trauma patients directly admitted from the scene or transferred to trauma centers from July 1, 2000, to June 30, 2011. Computer-aided dispatch flights were analyzed for periods corresponding to field triage protocol modifications intended to improve system efficiency. Outcomes were separately analyzed for trauma registry patients by mode of transport. RESULTS: The helicopter EMS computer-aided dispatch data set included 44,073 transports. There was a statewide decrease in helicopter EMS usage for trauma patients of 55.9%, differentially affecting counties closer to trauma centers. The Trauma Registry data set included 182,809 patients (37,407 helicopter transports, 128,129 ambulance transports, and 17,273 transfers). There was an increase of 21% in overall annual EMS scene trauma patients transported; ground transports increased by 33%, whereas helicopter EMS transports decreased by 49%. Helicopter EMS patient acuity increased, with an attendant increase in patient mortality. However, when standardized with W statistics, both helicopter EMS- and ground-transported trauma patients showed sustained improvement in mortality. CONCLUSION: Modifications to state protocols were associated with decreased helicopter EMS use and overall improved trauma patient outcomes.

Formation and function of acute stroke-ready hospitals within a stroke system of care recommendations from the brain attack coalition.

BACKGROUND AND PURPOSE: Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care. METHODS: The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke-Ready Hospitals (ASRHs). RESULTS: Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities. CONCLUSIONS: ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.

Rural mass casualty preparedness and response: the Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events.

The Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events hosted a workshop at the request of the Federal Interagency Committee on Emergency Medical Services (FICEMS) that brought together a range of stakeholders to broadly identify and confront gaps in rural infrastructure that challenge mass casualty incident (MCI) response and potential mechanisms to fill them. This report summarizes the presentations and discussions around 6 major issues specific to rural MCI preparedness and response: (1) improving rural response to MCI through improving daily capacity and capability, (2) leveraging current and emerging technology to overcome infrastructure deficits, (3) sustaining and strengthening relationships, (4) developing and sharing best practices across jurisdictions and sectors, (5) establishing metrics research and development, and (6) fostering the need for federal leadership to expand and integrate EMS into a broader rural response framework.

Revised and updated recommendations for the establishment of primary stroke centers: a summary statement from the brain attack coalition.

BACKGROUND AND PURPOSE: The formation and certification of Primary Stroke Centers has progressed rapidly since the Brain Attack Coalition's original recommendations in 2000. The purpose of this article is to revise and update our recommendations for Primary Stroke Centers to reflect the latest data and experience. METHODS: We conducted a literature review using MEDLINE and PubMed from March 2000 to January 2011. The review focused on studies that were relevant for acute stroke diagnosis, treatment, and care. Original references as well as meta-analyses and other care guidelines were also reviewed and included if found to be valid and relevant. Levels of evidence were added to reflect current guideline development practices. RESULTS: Based on the literature review and experience at Primary Stroke Centers, the importance of some elements has been further strengthened, and several new areas have been added. These include (1) the importance of acute stroke teams; (2) the importance of Stroke Units with telemetry monitoring; (3) performance of brain imaging with MRI and diffusion-weighted sequences; (4) assessment of cerebral vasculature with MR angiography or CT angiography; (5) cardiac imaging; (6) early initiation of rehabilitation therapies; and (7) certification by an independent body, including a site visit and disease performance measures. CONCLUSIONS: Based on the evidence, several elements of Primary Stroke Centers are particularly important for improving the care of patients with an acute stroke. Additional elements focus on imaging of the brain, the cerebral vasculature, and the heart. These new elements may improve the care and outcomes for patients with stroke cared for at a Primary Stroke Center.

Demonstration of a mode-conversion cavity add-drop filter.

We experimentally demonstrate a new type of add-drop filter incorporating an asymmetric Y-branch waveguide coupler and a shifted-grating mode-conversion cavity. The device relies on mode separation in the asymmetric Y-branch and wavelength-selective mode conversion upon reflection from the shifted-grating cavity. Add-drop functionality is demonstrated in a three-port integrated silicon-on-insulator device.

Effect of patient age on airway response by paramedics: frailty or futility?

OBJECTIVE: We studied patterns related to patient age and indication for airway interventions delivered by paramedics from 2000 through 2004. METHODS: The study population included patients ≥ 15 years old managed by paramedics. Outcomes were the frequencies of definitive airway, ventilatory techniques, and oxygenation techniques. Independent variables were patient age, gender, race, hospital drive time, do-not-resuscitate status, and two trauma indicators of the American College of Surgeons Committee on Trauma (anatomic injury and mechanism of injury). Subset analysis was performed with the presence or absence of a set of recorded conditions. RESULTS: A total of 827,772 paramedic transports were studied; 233,470 were identified with at least one indication for airway intervention. Patients older than 65 years were, when compared with patients 65 years old or younger, 1) less likely to receive ventilatory interventions with any indication; 2) more likely to receive ventilatory intervention without an indication; and 3) more likely to receive oxygenation interventions whether indications were present or not. We considered age in five-year intervals and noted a consistent biphasic pattern for all interventions, regardless of indications. The odds ratios for interventions for patients in each block compared with those for 15- to 29-year-old patients increased with age until about 70 years of age, then gradually declined. CONCLUSIONS: Patterns of age-related variations in airway interventions cannot be explained by the application of protocols. The reason for the peak rate of interventions at age 70 years is unknown. Explanations need to consider the influence on paramedic behavior of a number of factors, including frailty and futility. Additional paramedic training may be needed to change these patterns.

Rapid discharge after transfer: risk factors, incidence, and implications for trauma systems.

BACKGROUND: The occurrence of discharge to home shortly after transfer from another hospital, also termed "secondary overtriage," needs to be analyzed in trauma patients because it helps to assess the efficiency of triage and transfer criteria. The extent of secondary overtriage and factors associated with it remain largely undescribed. METHODS: A retrospective analysis of the Nationwide Inpatient Sample from 2000 to 2004. Inclusion criteria were trauma patients (as identified by ICD-9 diagnosis codes of 800-959 in the primary position, excluding codes representing late effects of injury, foreign body, burn, or early complications) who were admitted as transfers from another hospital. Rapid discharge after transfer (secondary overtriage) was defined as patients who were discharged alive within 1 day after transfer and did not receive any surgical procedure. RESULTS: The overall rate of secondary overtriage was 6.9% (3,291 of 51,278), with an increasing trend over the years. This rate was significantly higher among patients younger than 18 years (19.5% vs. 4.2%). Patients meeting the definition were more likely to be male (68.3% vs. 50.65%), more likely to be black or Hispanic (25.16% vs. 16.8%), more likely to come from ZIP codes with above-median household incomes (43.4% vs. 38.1%), and more likely to be treated at teaching hospitals (77.3% vs. 61.3%). The majority of these patients (98.7%) were insured, although the proportion of uninsured patients was significantly higher among secondary overtriage (1.3% vs. 0.54%). On multivariate analysis, younger age, uninsured status, and being transferred to a teaching hospital were associated with higher likelihood of rapid discharge after transfer. No association was found with gender, race, and urbanicity. CONCLUSION: Secondary overtriage is more common in pediatric patients than in adults. The underlying causes of this occurrence need to be further investigated (e.g., fear of litigation and uneven distribution of resources). There are significant direct and indirect costs associated with these occurrences that must be considered as we identify areas of potential cost savings in our nation's health care.

Regional systems of care for out-of-hospital cardiac arrest: A policy statement from the American Heart Association.

Out-of-hospital cardiac arrest continues to be an important public health problem, with large and important regional variations in outcomes. Survival rates vary widely among patients treated with out-of-hospital cardiac arrest by emergency medical services and among patients transported to the hospital after return of spontaneous circulation. Most regions lack a well-coordinated approach to post-cardiac arrest care. Effective hospital-based interventions for out-of-hospital cardiac arrest exist but are used infrequently. Barriers to implementation of these interventions include lack of knowledge, experience, personnel, resources, and infrastructure. A well-defined relationship between an increased volume of patients or procedures and better outcomes among individual providers and hospitals has been observed for several other clinical disorders. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. This statement describes the rationale for regional systems of care for patients resuscitated from cardiac arrest and the preliminary recommended elements of such systems. Many more people could potentially survive out-of-hospital cardiac arrest if regional systems of cardiac resuscitation were established. A national process is necessary to develop and implement evidence-based guidelines for such systems that must include standards for the categorization, verification, and designation of components of such systems. The time to do so is now.

Effects of short-term finasteride on apoptotic factors and androgen receptors in prostate cancer cells.

PURPOSE: We explored the molecular correlates of the effect of finasteride on prostate tissue in patients undergoing radical prostatectomy. MATERIALS AND METHODS: Patients undergoing radical prostatectomy for localized prostate cancer were eligible for study. After providing informed consent patients were randomized to receive 5 mg finasteride or placebo daily for at least 30 days before surgery. At surgery prostate tissue was harvested from the surgical specimen and sent for analysis. Tissue samples were analyzed for the pro-apoptotic factors caspase-3, caspase-7 and IGFBP-3. Samples were also analyzed for the tumor suppressor/proto-oncoproteins bcl-2, p53 and p21. Finally, tissues were analyzed for androgen receptor density and insulin growth factor-1. RESULTS: A total of 22 study and 20 placebo samples were collected and analyzed. Negligible staining for bcl-2 or caspase-3 was noted in each group. Statistical differences were not observed for bcl-2, p53, p21 or insulin growth factor-1 between the groups. There was a statistically significant difference in caspase-7 and IGFBP-3. A mean of 77% and 99.9% of cells stained for caspase-7 in the treatment and placebo groups, respectively (p = 0.007). In 3 patients caspase-7 staining disappeared completely and it was decreased by 70% and 50% in 1 patient each. Mean intensity staining for IGFBP-3 was 1.03 in the treatment group and 1.54 in the placebo group (p = 0.005). The staining intensity of nuclear androgen receptors on benign and cancerous cells was not significantly different between the treatment and placebo groups. However, there was a significant difference in androgen receptor staining between benign and cancer cells in the 2 populations. Mean nuclear androgen receptor staining intensity in all cancer and all benign tissue samples was 119.3 and 151.8, respectively (0.001). CONCLUSIONS: Finasteride administered 30 days before surgery appears to decrease the apoptotic factors caspase-7 and IGFBP-3 in cancer cells, while having little to no effect on caspase-3, insulin growth factor-1, bcl-2, p53 and p21. This short-term study may have interesting implications for interpreting Prostate Cancer Prevention Trial data on the molecular level. No differences were noted between the treatment and placebo groups in the expression of nuclear androgen receptor. However, decreased expression of androgen receptors was present in cancer cells compared to that in benign prostate cells in the 2 groups.

A regional system of stroke care provides thrombolytic outcomes comparable with the NINDS stroke trial.

STUDY OBJECTIVE: Administration of tissue plasminogen activator (tPA) for acute ischemic stroke remains controversial in community practice. Well-organized hierarchic systems of acute stroke care have been proposed to link community hospitals to comprehensive stroke centers. We report safety and functional outcomes in patients treated with tPA in our regional emergency stroke network and compare them with results reported from the trial conducted by the National Institute of Neurological Disorders and Stroke (NINDS). METHODS: Through a statewide communications and transport network, our brain attack center gives emergency medicine staff in the state and surrounding area immediate access to stroke specialists. The team provides consultation about the administration of tPA for ischemic stroke, using the NINDS protocol. Consultations, treatment, and outcomes are documented in our database. RESULTS: From 1996 to 2005, the brain attack center completed 2,670 consultations and diagnosed 1,788 patients with ischemic stroke. Two hundred forty patients (9% of all consultations; 13.4% of those with acute ischemic stroke) received tPA. Percentages of patients with symptomatic intracranial hemorrhage and 3-month modified Rankin scale scores less than or equal to 1, compared with those in the NINDS trial, were as follows: 3.3% versus 6.4% and 53% versus 43% (P=.04). Mortality rates were 13% (network) versus 17% (NINDS). CONCLUSION: During a 9-year period, an emergency medicine network with stroke consultants achieved patient outcomes comparable to those reported from the NINDS trial. These results indicate that the NINDS tPA protocol is applicable to community practice, with the support of a university-based brain attack center.

Undertriage of elderly trauma patients to state-designated trauma centers.

OBJECTIVE: To determine whether age bias is a factor in triage errors. DESIGN: Retrospective analysis of 10 years (1995-2004) of prospectively collected data in the statewide Maryland Ambulance Information System followed by surveys of emergency medical services (EMS) and trauma center personnel at regional EMS conferences and level I trauma centers, respectively. PATIENTS: Trauma patients were defined as those who met American College of Surgeons physiology, injury, and/or mechanism criteria and were subjectively declared priority I status by EMS personnel. MAIN OUTCOME MEASURE: Undertriage, defined as when trauma patients were not transported to a state-designated trauma center. RESULTS: The registry analysis identified 26 565 trauma patients. The undertriage rate was significantly higher in patients aged 65 years or older than in younger patients (49.9% vs 17.8%, P < .001). On multivariate analysis, this decrease in trauma center transports was found to start at age 50 years (odds ratio, 0.67; 95% confidence interval, 0.57-0.77), with another decrease at age 70 years (odds ratio, 0.45; 95% confidence interval, 0.39-0.53) compared with patients younger than 50 years. A total of 166 respondents participated in the follow-up surveys and ranked the top 3 causal factors for this undertriage as inadequate training, unfamiliarity with protocol, and possible age bias. CONCLUSIONS: Even when trauma is recognized and acknowledged by EMS, providers are consistently less likely to consider transporting elderly patients to a trauma center. Unconscious age bias, in both EMS in the field and receiving trauma center personnel, was identified as a possible cause.