Outcomes after severe head injury: a National Trauma Data Bank-based comparison of Level I and Level II trauma centers.

Severely head-injured patients require significant resources across the continuum of care. The objective of this study is to analyze the impact of the level of trauma center designation on the outcome of the severely head-injured patient. The National Trauma Data Bank between 2001 and 2006 (NTDB 6.2) was queried for all patients with isolated traumatic head injury and Glasgow Coma Score (GCS) less than 9. Comparisons between Level I and Level II trauma centers were made reviewing hospital length of stay (LOS), intensive care unit LOS, ventilator days, major complication rate (pulmonary embolism, pneumonia, lower extremity deep vein thrombosis), mortality, and discharge status. Chi-square and Student t tests were used to determine statistical significance defined as P < 0.05. There were 31,736 patients from 258 facilities who met the inclusion criteria during the study period. Level I trauma centers had approximately twice as many patients admissions as Level II centers. However, the severity of injuries and patients' characteristics identified by the emergency department GCS as well as the probability of survival score showed no difference between Level I and Level II centers. The comparisons between Level I and Level II trauma centers shows that Level II centers are not inferior to Level I in terms of outcomes and complication rate. Level II trauma centers encounter patients with isolated complex head injury less often but with outcomes and complication rates comparable to that of Level I centers. The transport of head-injured patients should not bypass Level II in favor of Level I.

Natural history of morbid obesity without surgical intervention.

BACKGROUND: To study the mortality among morbidly obese patients qualifying for bariatric surgery. Mortality from bariatric surgery for morbid obesity has been widely reported; however, little is known about the mortality in morbidly obese patients who defer surgery. METHODS: Consecutive patients evaluated for bariatric surgery with an initial encounter between 1997 and 2004 were identified. The Social Security Death Index and office records were used to identify mortality through 2006. We conducted telephone interviews to determine whether the 305 patients who did not undergo bariatric surgery at our institution had undergone the surgery elsewhere. Using Cox proportional hazards models, we compared the mortality in patients undergoing surgery with that of those who did not. To evaluate bias resulting from missing data, we conducted analyses assuming that all patients with missing data had (1) undergone surgery and (2) not undergone surgery. RESULTS: A total of 908 patients underwent bariatric surgery (880 patients at our institution and 28 patients elsewhere). A total of 112 patients did not undergo surgery. Data regarding surgery on 165 patients could not be obtained. The mortality in those patients who did not undergo surgery was 14.3% compared with 2.9% for those who did undergo surgery. Adjusting for age, gender, and body mass index, patients who had undergone surgery had an 82% reduction in mortality (hazard ratio 0.18, 95% confidence interval 0.09-0.35, P <.0001). Sensitivity analysis, assuming that all patients with missing data received surgery resulted in an 85% mortality reduction (P <.001) and assuming that patients did not receive surgery resulted in a 50% mortality reduction (P = .04). CONCLUSIONS: Mortality among morbidly obese patients without surgery was 14.3% during the study period. Surgical intervention offered a 50%-85% mortality reduction benefit.

The Clinical Research Forum and Association of American Physicians disagree with criticism of the NIH Roadmap.

As representatives of 50 leading academic medical centers focusing on clinical research and many of academic medicine's scientific leaders, the Clinical Research Forum and Association of American Physicians disagree with the JCI's recent editorials on the NIH Roadmap, Elias Zerhouni's leadership, and the future directions of biomedical research.

Age related effects in children taking the computerized assessment of response bias and word memory test.

The assessment of effort is a fundamental component of test performance analysis, since effort determines whether a psychological evaluation is valid. The assessment of effort in children has proven problematic. This may be related to the variable and inconsistent nature of children's developing self-regulatory systems, and the fact that measures commonly used to assess effort were standardized on adults. If one uses effort measures designed for adults to assess children, then one must presume that the maintenance of effort in children is comparable to the same behavior in adults. However, because children's executive functioning, including their abilities to self-regulate, attend, concentrate, and to engage in various cognitive activities improve with time (Barkley, 1997, pp. 209-234), our hypothesis is that young children's effort regulation is dissimilar to that of adults, and the presumption of similarity is implausible. The purpose of this study was to determine whether age is a significant influence upon young children's performances on the Computerized Assessment of Response Bias (CARB) and Word Memory Test (WMT). Statistical analysis suggests that younger children (those under 10 years of age) tended to produce poorer performance on these instruments. Younger children's scores differed significantly from children ages 10 and older. Children 11 years and older produced CARB and WMT results similar to adult participants, suggesting a viability for adult normative comparisons with children in this age range. The current investigation concluded that children's maintenance of effort appears to be significantly related to age and reading ability level. Consequently, the use of current adult-based norms with the CARB and WMT, without regard for a child's developmental status and other contextual factors such as the child's ability to read, appears ill-advised especially with children under 11 years of age.