Injury patterns in motor vehicle collision-youth pedestrian deaths.

OBJECTIVE: The objective of this study was to describe fatal pedestrian injury patterns in youth aged 15 to 24 years old and correlate them with motor vehicle collision (MVC) dynamics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian motor vehicle (MV) fleet. METHODS: Based on a systematic literature review, MVC-pedestrian injuries were collated in an injury data collection form (IDCF). The IDCF was coded using the Abbreviated Injury Scale (AIS) 2015 revision. The AIS of the most frequent severe injury was noted for individual body regions. The Maximum AIS (MAIS) was used to define the most severe injury to the body overall and by body regions (MAISBR). This study focused on serious to maximal injuries (AIS 3-6) that had an increasing likelihood of causing death. The IDCF was used to extract collision and injury data from the Office of the Chief Coroner for Ontario (OCCO) database of postmortem examinations done at the Provincial Forensic Pathology Unit (PFPU) in Toronto, Canada, and other provincial facilities between 2013 and 2019. Injury data were correlated with data about the MVs and MV dynamics and pedestrian kinematics.The study was approved by the Western University Health Science Research Ethics Board (Project ID: 113440; Lawson Health Research Institute Approval No. R-19-066). RESULTS: There were 88 youth, including 54 (61.4%) males and 34 (38.6%) females. Youth pedestrians comprised 13.1% (88/670) of all autopsied pedestrians. Cars (n = 25/88, 28.4%) were the most frequent type of vehicle in single-vehicle impacts, but collectively vehicles with high hood edges (i.e., greater distance between the ground and hood edge) were in the majority. Forward projection (n = 34/88, 38.6%) was the most frequent type of pedestrian kinematics. Regardless of the type of vehicle, there was a tendency in most cases for the median MAISBR ≥ 3 to involve the head and thorax. A similar trend was seen in most of the pedestrian kinematics involving the various frontal impacts. Of the 88 cases, at least 63 (71.6%) were known to be engaged in risk-taking behaviors (e.g., activity on roadway). At least 12 deaths were nonaccidental (8 suicides and 4 homicides). Some activities may have been impairment related, because 26/63 (41.3%) pedestrians undertaking risk-taking behavior on the roadway were impaired. Toxicological analyses revealed that over half of the cases (47/88, 53.4%) tested positive for a drug that could have affected behavior. Ethanol was the most common. Thirty-one had positive blood results. CONCLUSION: A fatal dyad of head and thorax trauma was observed for pedestrians struck by cars. For those pedestrians hit by vehicles with high hood edges, which were involved in the majority of cases, a fatal triad of injuries to the head, thorax, and abdomen/retroperitoneum was observed. Most deaths occurred from frontal collisions and at speeds more than 35 km/h.

Current trauma team activation processes at Canadian trauma centres: A national survey.

BACKGROUND: Trauma team activation (TTA) allows the provision of specialized and timely care to improve outcomes for severely injured patients. Limited information is available on the current state of TTA in Canadian trauma centres (TC). Study objectives were to describe TTA processes, data and reports, along with the challenges and successes from a national perspective. METHODS: A mixed-methods, cross-sectional survey was undertaken with Canadian trauma leadership, utilizing a total population sampling strategy. The questionnaire, containing 108-items, was administered online between February-April 2022, utilizing a modified Dillman technique. Descriptive statistics and thematic analyses were performed. RESULTS: Trauma leaders from 9 out of 10 provinces responded for a response rate of 68% (32/47). Two-thirds (67%) of respondents worked in adult TC; 63% in a level I center. A higher proportion of pediatric TC had a two-tiered TT response (60% pediatric; 35% adult). The most common criteria were neurologic compromise (100% one-level TTA) and hypotension (pediatric: 100% one-level, 100% tier 1; adult: 92% one-level, 86% tier 1). All one-level TTA included penetrating trauma criteria. One-third of respondents reported using TTA subgroup criteria for pediatric, pregnant, and/or geriatric patients. There was variability with disciplines responding to TTA, with largest, most comprehensive teams for tier 1. Two-thirds of TC review activation compliance (under/overtriage), while 55% focus on non-compliance and reasons for missed TTA. The most frequent challenges related to TTA practices were reliable data collection (60%) while successes included were the establishment of TTA guidelines to improve team compliance (33%) and RN initiated TTA. CONCLUSIONS: Some TTA practices were similar among Canadian TC, while others showed variability. Findings provide opportunities for improvement, including a two-tier system, geriatric-specific criteria, and RN initiated TTA, and could help establish national standards and best practices. Compliance with standards has the potential to improve Canadian TTA practices and patient outcomes.

A multicenter evaluation of pediatric emergency department injury visits during the COVID-19 pandemic.

BACKGROUND: Injuries, the leading cause of death in children 1-17 years old, are often preventable. Injury patterns are impacted by changes in the child's environment, shifts in supervision, and caregiver stressors. The objective of this study was to evaluate the incidence and proportion of injuries, mechanisms, and severity seen in Pediatric Emergency Departments (PEDs) during the COVID-19 pandemic. METHODS: This multicenter, cross-sectional study from January 2019 through December 2020 examined visits to 40 PEDs for children < 18 years old. Injury was defined by at least one International Classification of Disease-10th revision (ICD-10) code for bodily injury (S00-T78). The main study outcomes were total and proportion of PED injury-related visits compared to all visits in March through December 2020 and to the same months in 2019. Weekly injury visits as a percentage of total PED visits were calculated for all weeks between January 2019 and December 2020. RESULTS: The study included 741,418 PED visits for injuries pre-COVID-19 pandemic (2019) and during the COVID-19 pandemic (2020). Overall PED visits from all causes decreased 27.4% in March to December 2020 compared to the same time frame in 2019; however, the proportion of injury-related PED visits in 2020 increased by 37.7%. In 2020, injured children were younger (median age 6.31 years vs 7.31 in 2019), more commonly White (54% vs 50%, p < 0.001), non-Hispanic (72% vs 69%, p < 0.001) and had private insurance (35% vs 32%, p < 0.001). Injury hospitalizations increased 2.2% (p < 0.001) and deaths increased 0.03% (p < 0.001) in 2020 compared to 2019. Mean injury severity score increased (2.2 to 2.4, p < 0.001) between 2019 and 2020. Injuries declined for struck by/against (- 4.9%) and overexertion (- 1.2%) mechanisms. Injuries proportionally increased for pedal cycles (2.8%), cut/pierce (1.5%), motor vehicle occupant (0.9%), other transportation (0.6%), fire/burn (0.5%) and firearms (0.3%) compared to all injuries in 2020 versus 2019. CONCLUSIONS: The proportion of PED injury-related visits in March through December 2020 increased compared to the same months in 2019. Racial and payor differences were noted. Mechanisms of injury seen in the PED during 2020 changed compared to 2019, and this can inform injury prevention initiatives.

Pivoting injury prevention efforts during a pandemic: results of an international survey.

BACKGROUND: The COVID-19 a pandemic changed the world. Public health directives to socially distance with stay-at-home orders altered injury risk factor exposure, resulting injury patterns and conducting injury prevention (IP). The objective of this study was to determine the impact the COVID-19 pandemic on injury and IP at North American trauma centers (TC). RESULTS: Sixty-two responses were received from pediatric (44%), adult (11%), and combined (31%) TC, from 22 American states, 5 Canadian provinces and Australia. The majority (91%) of programs targeted age groups from birth to 15 years old. Nearly one-third reported IP to be less of an institutional priority with funding redistributed in 15% of centers [median (IQR) - 25% (- 43, 1)], and resultant staffing changes at 38% of centers. A decrease in IP efforts was reported at 64% of TC. Overall, the majority of respondents reviewed injury data, with the top reported increased mechanisms mainly intentional: Firearm-related (75%), assaults (72%), and abuse (71%). Leading increased unintentional injuries were injuries occurring in the home such as falls (70%), followed by ATV (62%), and cycling (57%). Sites pivoted by presenting (74%) or participating (73%) in IP education virtually, social media posts (61%) and the addition of technology (29%). Top barriers were redeployment of partners (45%) and staff (31%), as well as lack of technology (40%) in the target population. Facilitators were technology at TC (74%), support of trauma program (63%), and having IP funding maintained (55%). CONCLUSIONS: Nearly two-thirds of TC decreased IP efforts during the pandemic due to staffing and funding reductions. The leading reported increased injuries were intentional, indicating that violence prevention is needed, along with support for mental health. While TC successfully pivoted by using technology, access issues in the target population was a barrier resulting in health inequities.

Implementation of a road traffic crash injury surveillance tool in a trauma referral hospital in Kisumu City, Western Kenya: Lessons learned from the pilot study.

OBJECTIVE: Road traffic injury (RTI) is a major public health concern in Kenya with more than 13,000 deaths estimated annually. The primary objective of this study was to design and implement an injury surveillance tool for the collection of injury data, and assess the tool's feasibility for the development of a hospital-based trauma registry in a leading Kenyan referral hospital. Secondarily, an epidemiologic profile was created to characterize RTI in the region. METHODS: An injury surveillance tool was developed and implemented, on a pilot basis, in a level 5 trauma hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), in Kisumu City, Western Kenya, for a 4-week period from 2019-07-15 to 2019-08-11. A descriptive statistical analysis summarized injury frequency counts and percentages. RESULTS: Over the pilot phase, 371 patients had forms completed, but 488 official injury-related hospital registrations, indicating that 117 injury patients (24%) were missed. A process evaluation of the tool implementation revealed issues in the collection protocol that required revisions, resulting in improved data form completeness rates. For the 368 cases with cause documented, the most common mechanisms of injury were RTI (46.5%; n = 171), assaults (23.9%; n = 88), and falls (14.9%; n = 55). For RTI patients, the median age was 28 years (IQR = 16) and 77% (n = 132) were males, with motorbike collision injuries (n = 91; 53.2%) the leading RTI mechanism. There were 348 injuries for 171 patients. The most common anatomical regions for RTI were the lower limb 32.8% (n = 114), upper limb (15.2%; n = 53), followed by head lacerations 8.6% (n = 30) and concussions 7.2% (n = 25). Two-thirds of patients (n = 113; 66.1%) were discharged from ED, just over a quarter (n = 46; 26.9%) were admitted to hospital and 9 patients succumbed to RTI (5.3%). CONCLUSIONS: This injury surveillance pilot study produced the first injury dataset in Kisumu City, demonstrating the significant magnitude of RTI in Western Kenya, the leading cause of injury for the region. This dataset can be replicated in other hospitals to create an injury surveillance system for the collection of trauma data, needed for the development of countermeasures for the reduction of trauma, as well as for quality initiatives to improve patient outcomes.

Injury patterns in motor vehicle collision-pediatric pedestrian deaths.

OBJECTIVE: To describe fatal pediatric pedestrian injury patterns and correlate them with motor vehicle collision (MVC) characteristics and pedestrian kinematics using data from medicolegal death investigations of MVCs occurring in the current Canadian MV fleet and determine the applicability of the classical "Waddell's triad" comprising knee, hip (femur) or pelvis and craniocerebral injuries to present data injury patterns. METHODS: An Injury Data Collection Form was used to extract MV, MVC, pedestrian demographic and injury information from the Office of the Chief Coroner for Ontario database using autopsy data from 2013 to 2018. Injuries were coded using the Abbreviated Injury Scale (AIS) 2015 revision. The study focused on AIS ≥3 injuries utilizing the Maximum Abbreviated Injury Scale (MAIS), MAIS by Body Region (MAISBR) and Injury Severity Score (ISS). RESULTS: Between 2013 and 2018, there were 25 pediatric deaths. The pedestrians were either struck and run over (n = 17, 68%; 56% low speed) or struck and projected (n = 8, 32%). Twenty-two deaths were from frontal impacts; three were from reversing vehicles. Fourteen of the 17 (82.4%) run over cases occurred at low speed (<30 km/h). In 9 (36%) cases, the vehicle was turning at impact (right n = 3, left n = 6). A majority of the vehicles had a high hood edge. The head was the most severely injured (median MAISBR = 5 overall and ≤10 years; median MAISBR = 6 for 11-14 years old) followed by the neck (MAISBR = 3 overall; 6-14 years old), and the thorax (median MAISBR = 3 overall; all age groups). For the early adolescents (11-14 years old), the serious injury pattern included the abdomen (median MAISBR = 3.5). Nearly half (n = 11, 44%) sustained brainstem injuries. Over fifty percent of the 16 cases with neck injuries (n = 9, 56.3%) had atlanto-occipital or axial dislocation. CONCLUSION: More than half of the deaths occurred during low speed run overs. MAIS ≥3 injuries trended to a dyad of head and thorax in ≤5 years old, a triad of head, neck, and thorax injuries in children 6-10 years old and a tetrad with the addition of abdominal injuries in pedestrians ≥11 years old. Waddell's triad was not applicable to the fatal cases in the present study.

Pediatric severe traumatic brain injury mortality prediction determined with machine learning-based modeling.

INTRODUCTION: Severe traumatic brain injury (sTBI) is a leading cause of mortality in children. As clinical prognostication is important in guiding optimal care and decision making, our goal was to create a highly discriminative sTBI outcome prediction model for mortality. METHODS: Machine learning and advanced analytics were applied to the patient admission variables obtained from a comprehensive pediatric sTBI database. Demographic and clinical data, head CT imaging abnormalities and blood biochemical data from 196 children and adolescents admitted to a tertiary pediatric intensive care unit (PICU) with sTBI were integrated using feature ranking by way of a forest of randomized decision trees, and a model was generated from a reduced number of admission variables with maximal ability to discriminate outcome. RESULTS: In total, 36 admission variables were analyzed using feature ranking with variable weighting to determine their predictive importance for mortality following sTBI. Reduction analysis utilizing Borata feature selection resulted in a parsimonious six-variable model with a mortality classification accuracy of 82%. The final admission variables that predicted mortality were: partial thromboplastin time (22%); motor Glasgow Coma Scale (21%); serum glucose (16%); fixed pupil(s) (16%); platelet count (13%) and creatinine (12%). Using only these six admission variables, a t-distributed stochastic nearest neighbor embedding algorithm plot demonstrated visual separation of sTBI patients that lived or died, with high mortality predictive ability of this model on the validation dataset (AUC = 0.90) which was confirmed with a conventional area-under-the-curve statistical approach on the total dataset (AUC = 0.91; P < 0.001). CONCLUSIONS: Machine learning-based modeling identified the most clinically important prognostic factors resulting in a pragmatic, high performing prognostic tool for pediatric sTBI with excellent discriminative ability to predict mortality risk with 82% classification accuracy (AUC = 0.90). After external multicenter validation, our prognostic model might help to guide treatment decisions, aggressiveness of therapy and prepare family members and caregivers for timely end-of-life discussions and decision making. LEVEL OF EVIDENCE: III; Prognostic.

Development of a Mortality Prediction Tool in Pediatric Severe Traumatic Brain Injury.

Severe traumatic brain injury (sTBI) is a leading cause of pediatric death, yet outcomes remain difficult to predict. The goal of this study was to develop a predictive mortality tool in pediatric sTBI. We retrospectively analyzed 196 patients with sTBI (pre-sedation Glasgow Coma Scale [GCS] score <8 and head Maximum Abbreviated Injury Scale (MAIS) score >4) admitted to a pediatric intensive care unit (PICU). Overall, 56 patients with sTBI (29%) died during PICU stay. Of the survivors, 88 (63%) were discharged home, and 52 (37%) went to an acute care or rehabilitation facility. Receiver operating characteristic (ROC) curve analyses of admission variables showed that pre-sedation GCS score, Rotterdam computed tomography (CT) score, and partial thromboplastin time (PTT) were fair predictors of PICU mortality (area under the curve [AUC] = 0.79, 0.76, and 0.75, respectively; p < 0.001). Cutoff values best associated with PICU mortality were pre-sedation GCS score <5 (sensitivity = 0.91, specificity = 0.54), Rotterdam CT score >3 (sensitivity = 0.84, specificity = 0.53), and PTT >34.5 sec (sensitivity = 0.69 specificity = 0.67). Combining pre-sedation GCS score, Rotterdam CT score, and PTT in ROC curve analysis yielded an excellent predictor of PICU mortality (AUC = 0.91). In summary, pre-sedation GCS score (<5), Rotterdam CT score (>3), and PTT (>34.5 sec) obtained on hospital admission were fair predictors of PICU mortality, ranked highest to lowest. Combining these three admission variables resulted in an excellent pediatric sTBI mortality prediction tool for further prospective validation.

Evaluation of a population health strategy to reduce distracted driving: Examining all "Es" of injury prevention.

BACKGROUND: Cell phone use while driving (CPWD) increases the risk of crashing and is a major contributor to injuries and deaths. The objective of this study was to describe the evaluation of a multifaceted, evidence-based population health strategy for the reduction of distracted driving. METHODS: A multipronged campaign was undertaken from 2014 to 2016 for 16- to 44-year-olds, based on epidemiology, focused on personal stories and consequences, using the "Es" of injury prevention (epidemiology, education, environment, enforcement, and evaluation). Education consisted of distracted driving videos, informational cards, a social media AdTube campaign, and a movie theater trailer, which were evaluated with a questionnaire regarding CPWD attitudes, opinions, and behaviors. Spatial analysis of data within a geographic information system was used to target advertisements. A random sample telephone survey evaluated public awareness of the campaign. Increased CPWD enforcement was undertaken by police services and evaluated by ARIMA time series modeling. RESULTS: The AdTube campaign had a view rate of >10% (41,101 views), slightly higher for females. The top performing age group was 18- to 24-year-olds (49%). Our survey found 61% of respondents used handheld CPWD (14% all of the time) with 80% reporting our movie trailer made them think twice about future CPWD. A stakeholder survey and spatial analysis targeted our advertisements in areas of close proximity to high schools, universities, near intersections with previous motor vehicle collisions, high traffic volumes, and population density. A telephone survey revealed that 41% of the respondents were aware of our campaign, 17% from our print and movie theater ads and 3% from social media. Police enforcement campaign blitzes resulted in 160 tickets for CPWD. Following campaign implementation, there was a statistically significant mean decrease of 462 distracted driving citations annually (p = 0.001). CONCLUSION: A multifaceted, evidence-based population health strategy using the Es of injury prevention with interdisciplinary collaboration is a comprehensive method to be used for the reduction of distracted driving. LEVEL OF EVIDENCE: Therapeutic, level IV.

Concussion Acutely Decreases Plasma Glycerophospholipids in Adolescent Male Athletes.

Concussions are frequent in sports and can contribute to significant and long-lasting neurological disability. Adolescents are particularly susceptible to concussions, with accurate determination of the injury challenging. Our previous study demonstrated that concussion diagnoses could be aided by metabolomics profiling and machine learning, with particular weighting on changes in plasma glycerophospholipids (PCs). Here, our aim was to report directional change of PCs after concussion and develop a diagnostic concussion panel utilizing a minimum number of plasma PCs. To this end, we enrolled 12 concussed male athletes at our academic Sport Medicine Concussion Clinic, as well as 17 sex-, age-, and activity-matched healthy controls. Blood was drawn and 71 plasma PCs were measured for statistically significant changes within 72 h of injury, and individual PCs were further analyzed with receiver operating characteristic (ROC) curves. Our data demonstrated that 26 of 71 PCs measured were significantly decreased after sports-related concussion (p < 0.01). None of the PCs increased in plasma after concussion. ROC curve analyses identified the top four PCs with areas under the curve (AUCs) ≥0.86 for concussion diagnosis: PCaeC36:0 (0.92; p < 0.001); PCaaC42:6 (0.90; p < 0.001); PCaeC36:2 (0.86; p = 0.001), and PCaaC32:0 (0.86; p = 0.001). Cut-off values in µM were ≤0.31, 0.22, 5.07, and 4.63, respectively. Importantly, combining these four PCs produced an AUC of 0.96 for concussion diagnoses (p < 0.001; 95% confidence interval, 0.89, 1.00). Our data suggest that as few as four circulating PCs may provide excellent diagnostic potential for adolescent concussion. External validation is required in larger cohorts.

Does nifedipine improve outcomes of embryo transfer?: Interim analysis of a randomized, double blinded, placebo-controlled trial.

BACKGROUND: Implantation failure is the main factor affecting the success rate of in vitro fertilization (IVF) procedures. Studies have reported that uterine contractions (UC) at the time of embryo transfer (ET) were inversely related to implantation and pregnancy rate, hence reducing the success of IVF treatments. Various pharmacological agents, with the exception of calcium channel blockers, have been investigated to improve ET outcomes by reducing UC. Thus, a double-blinded randomized, placebo-controlled trial was conducted to determine whether nifedipine, a calcium channel blocker with potent smooth muscle relaxing activity and an excellent safety profile, can improve the outcome of patients undergoing ET treatments. METHODS: Ninety-three infertile women were recruited into 1 of 2 groups: placebo (n = 47) or nifedipine 20 mg (n = 46). Study participants were admitted 30 minutes prior to ET and given either tablet after their baseline vital signs were recorded. They then underwent ET and were observed for adverse events for another 30 minutes post-ET. Follow up of the participants' outcomes was conducted via electronic medical records. The primary outcomes are implantation and clinical pregnancy rates. Secondary outcomes include any maternal or fetal adverse events, miscarriage, pregnancy, live births, and neonatal outcomes. Resulting data were then analyzed using t test, Pearson chi-square test, and Fisher exact test to compare outcomes between the 2 groups. RESULTS: No statistical differences in the implantation rate (42.6% vs 39.1%, P = .737, rate ratio 0.868, 95% confidence interval [CI]: 0.379-1.986) and the clinical pregnancy rate (23.4% vs 26.1%, P = .764, rate ratio 1.155, 95% CI: 0.450-2.966) were detected between the placebo and the treatment groups. In addition, no statistical significance between the placebo and the treatment groups for any secondary outcomes were detected. CONCLUSIONS: This double blinded, randomized, and placebo-controlled trial demonstrated that the single use of 20 mg nifedipine given 30 minutes before embryo transfer did not improve the implantation rate or the clinical pregnancy rate of the infertility treatment. Further studies are required to demonstrate the clinical benefits and risks of nifedipine usage in embryo transfer.

Paroxysmal Sympathetic Hyperactivity After Severe Traumatic Brain Injury in Children: Prevalence, Risk Factors, and Outcome.

OBJECTIVE: To describe paroxysmal sympathetic hyperactivity in pediatric patients with severe traumatic brain injury using the new consensus definition, the risk factors associated with developing paroxysmal sympathetic hyperactivity, and the outcomes associated with paroxysmal sympathetic hyperactivity. DESIGN: Retrospective cohort study. SETTING: Academic children's hospital PICU. PATIENTS: All pediatric patients more than 1 month and less than 18 years old with severe traumatic brain injury between 2000 and 2016. We excluded patients if they had a history of five possible confounders for paroxysmal sympathetic hyperactivity diagnosis or if they died within 24 hours of admission for traumatic brain injury. MEASUREMENTS AND MAIN RESULTS: Our primary outcome was PICU mortality. One hundred seventy-nine patients met inclusion criteria. Thirty-six patients (20%) had at least eight criteria and therefore met classification of "likelihood of paroxysmal sympathetic hyperactivity." Older age was the only factor independently associated with developing paroxysmal sympathetic hyperactivity (odds ratio, 1.08; 95% CI, 1.00-1.16). PICU mortality was significantly lower for those with paroxysmal sympathetic hyperactivity compared with those without paroxysmal sympathetic hyperactivity (odds ratio, 0.08; 95% CI, 0.01-0.52), but PICU length of stay was greater in those with paroxysmal sympathetic hyperactivity (odds ratio, 4.36; 95% CI, 2.94-5.78), and discharge to an acute care or rehabilitation setting versus home was higher in those with paroxysmal sympathetic hyperactivity (odds ratio, 5.59; 95% CI, 1.26-24.84; odds ratio, 5.39; 95% CI, 1.87-15.57, respectively). When paroxysmal sympathetic hyperactivity was diagnosed in the first week of admission, it was not associated with discharge disposition. CONCLUSIONS: Our study suggests that the rate of paroxysmal sympathetic hyperactivity in patients with severe traumatic brain injury is higher than previously reported. Older age was associated with an increased risk for developing paroxysmal sympathetic hyperactivity, but severity of the trauma and the brain injury were not. For survivors of severe traumatic brain injury beyond 24 hours who developed paroxysmal sympathetic hyperactivity, there was a lower PICU mortality but also greater PICU length of stay and a lower likelihood of discharge home from the admitting hospital, suggesting that functional outcome in survivors with paroxysmal sympathetic hyperactivity is worse than survivors without paroxysmal sympathetic hyperactivity.

A double-blinded, randomized, placebo-controlled trial assessing the effects of nifedipine on embryo transfer: Study protocol.

INTRODUCTION: Implantation failure is the main factor affecting the success rate of in vitro fertilization (IVF) procedures. Studies have reported that uterine contractions (UCs) at the time of embryo transfer (ET) were inversely related to implantation and pregnancy rate, hence reducing the success of IVF treatment. Various pharmacological agents, with the exception of calcium channel blocker (CCB), have been investigated to reduce UC. In this regard, we are presenting a proposal for a double-blind randomized placebo-controlled trial. The trial aims to determine whether nifedipine, a CCB with potent smooth muscle relaxing activity and an excellent safety profile, can improve the outcome of ET. METHODS AND ANALYSES: We will recruit 100 infertile women into one of 2 groups: placebo (n = 50) and nifedipine 20 mg (n = 50). Study participants will be admitted 30 minutes prior to ET and given either tablet after their baseline vital signs have been recorded. They will then undergo ET and be observed for adverse events for another 30 minutes post-ET. The primary outcome will be implantation rate and clinical pregnancy rate. Secondary outcomes include adverse events, miscarriage and pregnancy, and neonatal outcomes. Resulting data will then be analyzed using t test, Chi-square test, and multivariate test to compare outcomes between the 2 groups for any statistical significance. This protocol has been designed in accordance with the SPIRIT 2013 Guidelines.

Radiographic assessment of degenerative lumbar spinal stenosis: is MRI superior to CT?

OBJECTIVE: To determine the reliability and dependability of magnetic resonance imaging (MRI) and computerized tomography (CT) in the assessment of lumbar spinal stenosis and correlate the qualitative assessment to both a quantitative assessment and functional outcome measures. Multiple studies have addressed the issue of CT and MRI imaging in lumbar spinal stenosis. None showed superiority of one modality. METHODS: We performed a standardized qualitative and quantitative review of CT and MRI scans of 54 patients. Intra-observer and inter-observer reliability was determined between three reviewer using Kappa coefficient. Agreement between the two modalities was analyzed. ODI and SF-36 outcomes were correlated with the imaging assessments. RESULTS: Almost perfect intra-observer reliability for MRI was achieved by the two expert reviewers (κ = 0.91 for surgeon and κ = 0.92 for neuro-radiologist). For CT, substantial intra-observer agreement was found for the surgeon (κ = 0.77) while the neuro-radiologist was higher (κ = 0.96). For both CT and MRI the standardized qualitative assessment used by the two expert reviewers had a better inter-observer reliability than that between the expert reviewers and the general reporting radiologist, who did not utilize a standardized assessment system. When the qualitative assessment was compared directly, CT overestimated the degree of stenosis 20-35 % of the time (p < 0.05) while MRI overestimated the degree of stenosis 2-11 % of the time (p < 0.05). No correlation was found between qualitative and quantitative analysis with functional status. CONCLUSIONS: This study directly demonstrates that MRI is a more reliable tool than CT, but neither correlates with functional status. Both experience of the reader and the standardization of a qualitative assessment are influential to the reliability.

Did Amendments to the Ontario Highway Traffic Act in 2009-2010 Affect the Proportion of Alcohol-Related Motor Vehicle Collisions Seen at a Level I Trauma Centre over a 10-year Period?

OBJECTIVES: To determine if changes to the Ontario Highway Traffic Act (OHTA) in 2009 and 2010 had an effect on the proportion of alcohol-related motor vehicle collisions (MVCs) presenting to a trauma centre over a 10-year period. METHODS: A retrospective review of the trauma registry at a Level I trauma centre in southwestern Ontario was undertaken. The trauma registry is a database of all trauma patients with an injury severity score (ISS) ≥12 and/or who had trauma team activation. Descriptive statistics were calculated. Interrupted time series analyses with ARIMA modeling were performed on quarterly data from 2004-2013. RESULTS: A total of 377 drivers with a detectable serum ethanol concentration (SEC) were treated at our trauma centre over the 10-year period, representing 21% of all MVCs. The majority (330; 88%) were male. The median age was 31 years, median SEC was 35.3 mmol/L, and median ISS was 21. A total of 29 (7.7%) drinking drivers died from their injuries after arriving to hospital. There was no change in the proportion of drinking drivers after the 2009 amendment, but there was a significant decline in the average SEC of drinking drivers after changes to the law. There was no difference in the proportion of drinking drivers ≤21 years after introduction of the 2010 amendment for young and novice drivers. CONCLUSIONS: There was a significance decline in the average SEC of all drinking drivers after the 2009 OHTA amendment, suggesting that legislative amendments may have an impact on drinking before driving behaviour.

Home safe home: Evaluation of a childhood home safety program.

BACKGROUND: The London Health Sciences Centre Home Safety Program (HSP) provides safety devices, education, a safety video, and home safety checklist to all first-time parents for the reduction of childhood home injuries. The objective of this study was to evaluate the HSP for the prevention of home injuries in children up to 2 years of age. METHODS: A program evaluation was performed with follow-up survey, along with an interrupted time series analysis of emergency department (ED) visits for home injuries 5 years before (2007-2013) and 2 years after (2013-2015) implementation. Spatial analysis of ED visits was undertaken to assess differences in home injury rates by dissemination areas controlling differences in socioeconomic status (i.e., income, education, and lone-parent status) at the neighborhood level. RESULTS: A total of 3,458 first-time parents participated in the HSP (a 74% compliance rate). Of these, 20% (n = 696) of parents responded to our questionnaire, with 94% reporting the program to be useful (median, 6; interquartile range, 2 on a 7-point Likert scale) and 81% learning new strategies for preventing home injuries. The median age of the respondent's babies were 12 months (interquartile range, 1). The home safety check list was used by 87% of respondents to identify hazards in their home, with 95% taking action to minimize the risk. The time series analysis demonstrated a significant decline in ED visits for home injuries in toddlers younger than2 years of age after HSP implementation. The declines in ED visits for home injuries remained significant over and above each socioeconomic status covariate. CONCLUSION: Removing hazards, supervision, and installing safety devices are key facilitators in the reduction of home injuries. Parents found the HSP useful to identify hazards, learn new strategies, build confidence, and provide safety products. Initial finding suggests that the program is effective in reducing home injuries in children up to 2 years of age. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Very early initiation of chemical venous thromboembolism prophylaxis after blunt solid organ injury is safe.

BACKGROUND: The optimal timing of initiating low-molecular weight heparin (LMWH) in patients who have undergone nonoperative management (NOM) of blunt solid organ injuries (SOIs) remains controversial. We describe the safety of early initiation of chemical venous thromboembolism (VTE) prophylaxis among patients undergoing NOM of blunt SOIs. METHODS: We retrospectively studied severely injured adults who sustained blunt SOI without significant intracranial hemorrhage and underwent an initial NOM at a Canadian lead trauma hospital between 2010 and 2014. Safety was assessed based on failure of NOM, defined as the need for operative intervention, in patients who received early (< 48 h) or late LMWH (≥ 48 h, or early discharge [< 72 h] without LMWH). RESULTS: We included 162 patients in our analysis. Most were men (69%), and the average age was 42 ± 18 years. The median injury severity score was 17, and splenic injuries were most common (97 [60%], median grade 2), followed by liver (57 [35%], median grade 2) and kidney injuries (31 [19%], median grade 1). Combined injuries were present in 14% of patients. A total of 78 (48%) patients received early LMWH, while 84 (52%) received late LMWH. The groups differed only in percent of high-grade splenic injury (14% v. 32%). Overall 2% of patients failed NOM, none after receiving LMWH. Semielective angiography was performed in 23 (14%) patients. The overall rate of confirmed VTE on imaging was 1.9%. CONCLUSION: Early initiation of medical thromboembolic prophylaxis appears safe in select patients with isolated SOI following blunt trauma. A prospective multicentre study is warranted.

An evidence-based method for targeting an abusive head trauma prevention media campaign and its evaluation.

BACKGROUND: A triple-dose abusive head trauma (AHT) prevention program (Period of PURPLE Crying) was implemented. The third dose consisted of an education media campaign. The study objectives were to describe the qualitative and spatial methods developed to target AHT prevention and to evaluate this campaign. METHODS: A questionnaire on the level of importance of factors, rated on a 7-point Likert scale, was distributed to a panel of experts to determine the best advertising locations. Ranked factors were used to create weights for statistical modeling and mapping within a Geographic Information Systems to determine optimal ad locations. The media campaign was evaluated via a telephone survey of randomly selected households. RESULTS: The survey found locations of new families, high population density, and high percentage of lone parents to be the most important factors for selecting billboard sites. Spatial analysis revealed six areas that ranked highest in our factors. Five billboards, four media posters, and six transit shelters were selected for our advertisements. A population-based telephone survey revealed that 23% of respondents knew the campaign. Nearly half (42%) heard the radio public service announcements, and 9% saw billboards. CONCLUSION: Extending primary prevention efforts to the public helps to create a cultural change in the way inconsolable crying, the trigger for AHT, is viewed. With the use of ranked factors and Geographic Information Systems, geographic locations with high visibility and specific risk factors for AHT were identified for targeting the campaign, facilitating the likelihood that our message was reaching the population in greatest need.

From focus groups to production of a distracted driving video: Using teen input to drive injury prevention programming.

BACKGROUND: The Impact program is an adolescent, injury prevention program with both school- and hospital-based components aimed at decreasing high-risk behaviors and preventing injury. The objective of this study was to obtain student input on the school-based component of Impact, as part of the program evaluation and redesign process, to ensure that the program content and format were optimal and relevant, addressing injury-related issues important for youth in our region. METHODS: Secondary schools were selected in various geographic regions with students varying in language, religion, and socioeconomic status. A mixed-methods questionnaire was developed and pretested on program content, format, relevance, quality, and effectiveness. Attitude and opinion questions on issues facing teens today were ranked on a 7-point Likert scale. Open-ended, qualitative questions were included in the focus groups, with responses themed. RESULTS: There were 167 respondents in the nine geographically, socioeconomically, and culturally diverse focus groups with a mean age of 16 years, 52% were male, and 69% were in Grade 11. Ninety-three percent of respondents rated the content of Impact as comprehensive (median, 6 of 7, with 7 being very comprehensive), and 29% rated the format a 5 of 7. Impact was rated relevant (89%), addressing issues for teens (median, 6 of 7). Issues suggested to highlight included texting and driving, drugs, partying, self-harm, and abusive relationships. Texting while driving was perceived as a significantly more common (81%) injury issue for adolescents compared with other driving risk factors (p < 0.001), with one student commenting, "If you don't (text and drive), you either don't have a phone or don't have a driver's license." CONCLUSION: Injury prevention programs must be continually evaluated to ensure they are relevant, addressing issues important for youth, and presented in a format that resonates with the audience. Student focus groups identified motor vehicle collisions and texting as important issues as well as a desire for teens to hear personal stories with a visual element. This provided the information needed to develop the next logical direction for our program, the production of a distracted driving video ("Distracted Driving: Josh's Story," http://youtu.be/BFPke9gBybc) to be incorporated into school presentations. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Basal skull fractures are associated with mortality in pediatric severe traumatic brain injury.

BACKGROUND: Basal skull fractures (BSFs) are caused by blunt force trauma, occurring in the temporal, occipital, sphenoid, and/or ethmoid bones. In pediatric severe traumatic brain injury (sTBI), there is a paucity of data on BSFs. Our goal was to investigate the BSF prevalence, anatomy, and association with short-term outcomes in pediatric sTBI. METHODS: We retrospectively reviewed all severely injured (Injury Severity Score ≥12) pediatric patients (aged <18 years) admitted to our hospital after experiencing an sTBI (Glasgow Coma Scale score ≤8 and head Abbreviated Injury Scale score ≥4). Neuroimaging for all sTBI patients was reviewed for skull fractures. Data were analyzed with both univariate and multivariate techniques. RESULTS: Of the 180 patients with sTBI, 47 had BSFs for a prevalence of 26% (69 BSFs in total; 16 sTBI patients had ≥2 BSFs). The squamous temporal bone was fractured most frequently (n=30/47 sTBI patients with BSFs). Patients with BSFs were heavier and had more facial injuries than those without (p < 0.05) but were similar in all other admission demographics, injury profiles, and clinical characteristics. Cerebrospinal fluid leak was found in 32% (n = 15 of 47) of BSF patients (otorrhea, n = 12; rhinorrhea, n = 1; otorrhea/rhinorrhea, n = 2; p < 0.001). Mortality, acute central diabetes insipidus, and fewer ventilator-free days were associated with BSFs (p < 0.005), whereas in sTBI survivors, BSFs were associated with longer lengths of stay (p < 0.05). Multiple logistic regression showed that BSFs were positively associated with the presence of subarachnoid hemorrhage (odds ratio [OR], 4.00; p = 0.001), contusion (OR, 2.48; p = 0.029), herniation (OR, 3.40; p = 0.037), and cerebral edema (OR, 2.30; p = 0.047) but negatively associated with diffuse axonal injury (OR, 0.20; p = 0.003). BSFs and mortality were strongly associated (OR, 6.87; p = 0.019). CONCLUSION: BSFs occurred in 26% of pediatric sTBI patients. The temporal bone was fractured in two thirds of sTBI patients with BSFs, and one third was associated with cerebrospinal fluid leaks. BSFs represent a significant linear blunt force and are independent predictors of mortality. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.