Hidden spears: handlebars as injury hazards to children.

OBJECTIVES: To delineate the mechanism of serious bicycle handlebar-related injuries in children and make recommendations for preventive strategies. METHODS: Prospective cross-sectional surveillance system of seriously injured child bicyclists supplemented by in-depth, on-site crash investigation to delineate specific injury mechanisms. Interdisciplinary analyses involved engineers, clinicians, epidemiologists, and biostatisticians. SETTING: The emergency department and in-patient trauma service of an urban level one pediatric trauma center between October 1995 and September 1997. PARTICIPANTS: Patients under 18 years of age who were treated for serious bicycle-related injuries (Abbreviated Injury Scale scores of 2 or greater). RESULTS: The surveillance system identified two distinct circumstances for serious child bicyclist injury: 1) handlebar-related injuries associated with minor incidents (falls from bicycles) and 2) nonhandlebar-related injuries associated with severe incidents (bicycle-motor vehicle crashes). Crash investigations explored the minor incidents that resulted in serious handlebar-associated injuries. In the typical mechanism, as the child lost control of the bicycle and began to fall, the front wheel rotated into a plane perpendicular to the child's body. The child then landed on the end of the handlebar resulting in serious truncal injuries. CONCLUSIONS: A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. Recognition of the mechanism of handlebar-related injuries might aid the practitioner in early diagnosis of serious abdominal injuries in child bicyclists. This injury mechanism may be avoided through bicycle redesign that would involve both limiting rotation of the front wheel and modifying the ends of handlebars. An integrated approach involving a surveillance system to identify an injury hazard supplemented by in-depth, on-site crash investigations effectively provided the detailed mechanism of injury needed to develop interventions.

The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy.

OBJECTIVE: To determine the short-term medical outcome of hypoglycemic insulin-dependent diabetic patients who refuse transport after out-of-hospital therapy and return to baseline mental status. METHODS: Prospective, descriptive, short-term medical outcome data for adult patients were collected between May 1996 and December 1996. Paramedics responding to the aid of hypoglycemic insulin-dependent diabetic patients who refused transport after administration of dextrose solution (D50W) contacted a medical command physician at the University of Pennsylvania. The patients' medical histories, names, addresses, and telephone numbers were recorded. Three days after their hypoglycemic episodes, these patients were contacted by telephone by a registered nurse to determine their medical conditions. RESULTS: Of 132 patients enrolled in the study, 103 (78%) could be contacted by telephone follow-up. Ninety-four (91%) of these patients had no recurrence of symptoms. Nine patients (9%) had recurrence of hypoglycemia and recontacted 911. Eight of these (8%) were transported to a hospital via ambulance and 3 (3%) were admitted, 1 (1%) for a cancer-related illness and 2 (2%) for hypoglycemia, 1 of whom died (1%). The remaining patient refused transport a second time after being treated, despite having the risks of refusal explained to him by a medical command physician. CONCLUSIONS: The practice of treating and releasing most hypoglycemic insulin-dependent diabetic patients who return to normal mental status after D50W administration appears in general to be safe. Patients should be advised of the risks of recurrent hypoglycemia.

Olfactory dysfunction in patients with head trauma.

BACKGROUND: The ability to smell is commonly altered by head trauma (HT). However, the nature, prevalence, prognosis, and etiology of such alterations are poorly understood. OBJECTIVES: To quantitatively determine the degree of olfactory function in patients with HT-related chemosensory complaints and to examine the influences of age, sex, HT severity, time since HT, and other variables on such function. Also, to use quantitative magnetic resonance imaging (MRI) to establish whether and to what degree damage to the olfactory bulbs and tracts, frontal lobes, and temporal lobes occurs. PATIENTS AND METHODS: Two hundred sixty-eight patients with HT from the University of Pennsylvania Smell and Taste Center, Philadelphia, were administered a quantitative odor identification test, a depression inventory, and a medical history questionnaire; 66 were retested after individual test-retest periods ranging from 1 month to 13 years. The volume of olfactory-related brain structures was determined in 15 patients and 15 controls using MRI. RESULTS: One hundred seventy-nine patients (66.8%) had anosmia, 55 (20.5%) had microsmia, and 34 (12.7%) had normosmia. Frontal impacts produced less dysfunction than back or side impacts. Of the 66 retested patients, 24 (36%) improved slightly, 30 (45%) had no change, and 12 (18%) worsened; only 3 patients, none of whom initially had anosmia, regained normal olfactory function. Trauma severity was related to olfactory test scores in patients with microsmia. Parosmia prevalence decreased from 41.1% to 15.4% over an 8-year posttrauma period. Olfactory bulb and tract volumes of male, but not female, patients with HT were greatly reduced relative to volumes of controls. CONCLUSIONS: Patients complaining of HT-related olfactory dysfunction typically have anosmia and rarely regain normal olfactory ability, parosmia prevalence decreases over time in such patients, and damage to olfaction-related brain structures can be observed in most such patients using an appropriate MRI protocol.