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Abstract: Objective: To document the population-based incidence of sexual assault in Baltimore, Md, victims'' alcohol/drug use, and pre-event circumstances. Methods: Between 1997 and 1999, the city''s sexual assault treatment center treated 1,038 victims (age ≥ 13 years). Data were extracted from forensic narratives. Analysis was restricted to frequency tables and bar graphs. Incidence was calculated based on 1998 population figures. Results: The incidence of sexual assault among females aged 13 years or older was 117 per 100000. Seventy percent of patients were less than 30 years old. Fifty-three percent tested positive for alcohol/drugs. Two thirds sustained physical or genital injury; 30% sustained both. The most common pre-event circumstances were walking/being followed (27%) and visiting a friend''s home (24%). Conclusion: This study revealed a high prevalence of physical/genital injury, supporting the call for an injury severity scale for sexual assault and for increased substance abuse counseling and educational/health resources to mitigate sexual assault and offer meaningful response when such crimes occur. [Copyright &y& Elsevier]

Objective: To assess the prevalence of psychoactive substance use disorders (PSUDs) among a large, unselected group of seriously injured trauma center patients, using a standardized diagnostic interview and criteria.Design: Prevalence study.Setting: A level I regional trauma center.Patients: Trauma center patients fulfilling the following criteria were eligible subjects: aged 18 years or older, admission from injury scene, length of stay of 2 days or longer, and intact cognition.Outcome Measures: The PSUDs were diagnosed using the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) and were categorized as abuse or dependence and past or current (within past 6 months). The SCID results were analyzed with respect to demographic factors, injury type, and blood alcohol concentration and urine toxicology results, using chi2 and logistic regression techniques.Results: Of the 1220 patients approached for study, 1118 (91.6%) consented. More than half (54.2%) had a diagnosis of a PSUD in their lifetime. Approximately 90% of alcohol and other drug use diagnoses were for dependence and more than 62% were current. Overall, 24.1% of patients were currently alcohol dependent (men, 27.7%; women, 14.7%; P<.001), and 17.7% were currently dependent on other drugs (men, 20.2%; women, 11.2%; P<.001). Current alcohol dependence rates were not associated with race; rates of dependence on other drugs were higher among nonwhites and victims classified with intentional injuries. While 54.3% of blood alcohol-positive patients were currently alcohol dependent and 38.7% of patients with positive urine screening test results for drugs other than alcohol and nicotine were currently drug dependent, 11.7% of blood alcohol-negative and 3.9% of drug-negative patients, respectively, had current diagnoses of dependence on psychoactive substances.Conclusions: A high percentage of seriously injured trauma center patients are at risk of having current PSUDs. Patients with positive toxicology screening test results and/or positive screening questionnaire responses should be referred for formal evaluation and treatment. [ABSTRACT FROM AUTHOR]

Lower extremity injuries resulting from motor vehicle crashes are common and have become relatively more important as more drivers with newer occupant restraints survive high-energy crashes. CIREN data provide a greater level of clinical detail based on coding guidelines from the Orthopedic Trauma Association. These detailed data, in conjunction with long-term follow-up data obtained from patient interviews, reveal that the most costly and disabling injuries are those involving articular (joint) surfaces, especially those of the ankle/foot. Patients with such injuries exhibit residual physical and psychosocial problems, even at one year post-trauma.

Background: Data using crash dummies suggest that motor vehicle crashes (MVCs) involving passenger sedans (S) vs sport utility, vans, or light trucks (SUVTs) produce more severe injuries than those involving two sedans (SvS). However, no detailed data regarding pattern of injuries or force mechanisms involved have been presented in real patients., Methods: The relationship of injury patterns and severities with MVC reconstruction data were obtained in 412 MVC patients, drivers or front seat passengers. Crashes were examined with regard to impact direction, frontal (F) or lateral (L) crashes, vehicle mass ratio, ISS, DELTA V, seat belt use, and airbag deployment (AB)., Results: In 309 F-MVC, AB reduced overall ISS (24.3 to 17.9) with a reduction in the mean severity of traumatic brain injury (TBI) GCS < or = 12, from 48% to only 28%. This AB protection from TBI was preserved as DELTA V increased to > 30 mph even though non-AB protected body areas (thorax, lung, liver, and lower extremity injuries) all increased. When vehicles of incompatible size and mass (SUVT) had F-MVC with sedans the incidence of severe TBI rose as did face lacerations despite AB or belt use. In L-MVC between SUVT and sedans compared with SvS MVC, there was a cephalad shift in body injuries with increased thorax, but decreased lower extremity injuries. The incidence of TBI increased. Analysis of injury contact sites (hits) showed more hits and a wider distribution of contract sites in SUVT vs sedan MVC. These appeared due to the greater mass excess and larger mass ratio, hood height, and width in the F-SUVT vs S crashes. All of these factors plus the increased bumper height above the body frame side-door sill were injury causal factors in the L-SUVT vs S MVCs., Conclusion: Both F and L crashes between sedans and SUVT with a high mass ratio shift the pattern of injury cephalad with increased thorax and intrathoracic organ injuries, and more severe TBI. These data suggest that improved head and thorax side-impact buffering and design features which transmit MVC forces from the higher front end of the larger mass SUVT to the frame of the sedan may better protect sedan occupants from side-impacts.

Background: Despite the current emphasis on injury prevention, little has been done to incorporate alcohol intervention programs into the care of the injured patient. The purpose of this study was to determine whether patients admitted to a trauma center with positive toxicology findings (TOX+) have a higher subsequent injury mortality than those without such findings (TOX-)., Methods: We followed a cohort of 27,399 trauma patients discharged alive between 1983 and 1995 to determine subsequent mortality. Death certificates were obtained to identify the cause of death., Results: TOX+ patients had an injury mortality rate approximately twice that of the TOX- group (1.9% vs. 1.0%, p < 0.001). Overall, 22.7% of the deaths were due to injury; the TOX+ rate was 34.7% versus 15.4% for the TOX-., Conclusion: These data add strength to the premise that untreated substance abuse-related injury remains an untapped injury prevention opportunity.

Background: Although reports have documented alcohol and other drug use by trauma patients, no studies of long-term trends have been published. We assessed substance use trends in a large cohort of patients admitted to a regional Level I adult trauma center between July 1984 and June 2000., Methods: Positive toxicology results, collected via retrospective database review, were analyzed for patients admitted directly to the center. Data were abstracted from a clinical toxicology database for 53,338 patients. Results were analyzed for alcohol, cocaine, and opiates relative to sex, age (< 40/> or = 40 years), and injury type (nonviolence/violence). Positive toxicology test result trends were assessed for the 3 years at the beginning and end of the period (chi2). Testing biases were assessed for sex, race, and injury type., Results: The patient profile was as follows: men, 72%; age < 40 years, 69%; nonviolence victims, 77%. Alcohol-positive results decreased 37%, but cocaine-positive and opiate-positive results increased 212% and 543%, respectively (all p < 0.001). Cocaine-positive/opiate-positive results increased 152%/640% for nonviolence and 226%/258% for violence victims, respectively (all p < 0.001). In fiscal year 2000, cocaine-positive and opiate-positive results were highest among violence victims (27.4% for both drugs). Cocaine-positive and opiate-positive results among nonviolence victims were 9.4% and 17.6%, respectively. Patients who were minorities or victims of violence were not tested more frequently than other patients., Conclusion: Epidemic increases in cocaine and opiate use were documented in all groups of trauma patients, with the greatest increases being in violence victims. Alcohol use decreased for all groups.

Most previous studies of medical conditions associated with driver safety have focused on specific diseases. This analysis is based on a linkage of police report and hospital discharge data, and correlates various medical diagnostic categories and specific conditions with police determinations of driver culpability for all drivers admitted to Maryland hospitals during a 3-year period. Using odds ratios, various conditions have been identified which are associated with an increased risk of crash culpability. Further research is needed to confirm these findings, and to determine the role of the conditions vs. the possible influence of medications prescribed to treat these conditions.

Objective: To assess the utility of laboratory markers of severe alcoholism in a cross-sectional population of male trauma center patients, who have a high rate of current alcohol dependence (CAD)., Methods: A total of 684 men were assessed for CAD by using standard criteria, all of whom had complete laboratory data. The ability of tests to predict CAD was ascertained by using Student's t test, sensitivity, specificity, and area under the curve (AUC) of receiver operating characteristic curves., Results: Mean values of five tests were individually associated with a CAD diagnosis. Gamma-glutamyltransferase, aspartate aminotransferase, and mean corpuscular volume had sensitivities less than or equal to 0.51 and AUC less than or equal to 0.67. Blood alcohol concentration (BAC) and serum osmolality had sensitivities of 0.64 and 0.74 and AUC of 0.74 and 0.76, respectively. Each marker, when combined with BAC, showed little improvement in AUC over BAC alone., Conclusions: Laboratory tests are not highly predictive of CAD in male trauma patients. A combination of BAC tests and interview screens is suggested for use in this patient population.

Objective: To evaluate the accuracy of questionnaire screening instruments to identify lifetime alcohol dependence among trauma center patients., Methods: The study was conducted at a Level I trauma center between September 1994 and November 1996. Patients meeting eligibility requirements (> or = 18 years old, admission from injury scene, > or = 2 days of hospitalization, intact cognition) were evaluated for alcohol abuse and dependence. Screening instruments consisted of the CAGE, the Brief Michigan Alcoholism Screening Test, and the Alcohol Use Disorders Identification Test. Screening results were compared with lifetime alcohol dependence diagnoses made using the in-depth Psychoactive Substance Use Disorders section of the Structured Clinical Interview. Accuracy was quantified as sensitivity, specificity, positive/negative predictive values, and receiver operating characteristic curves (used to calculate area under the curve)., Results: Of the 1,118 patients studied, lifetime alcohol dependence was diagnosed by Structured Clinical Interview in 397 (35.5%), and abuse was diagnosed in 90 (8.1%) others. The CAGE was the best predictor of lifetime alcohol dependence, i.e., had the largest area under the curve (93%) and the highest sensitivity (84%), specificity (90%), positive predictive value (82%), and negative predictive value (91%). Among patients testing positive for alcohol, 63% had a lifetime alcohol dependence diagnosis., Conclusion: The CAGE is an efficient screening test to detect alcohol dependence in trauma center populations. It should be used in combination with alcohol testing to identify patients at risk of alcohol use problems.

Objective: To develop a simple model for identification of trauma patients who are likely to have a blood alcohol concentration > or = 50 mg/dL (BAC + 50)., Methods: Demographic, clinical, and BAC data were collected from the clinical trauma registry and toxicology data base at a Level I trauma center. Logistic regression was used to analyze data from 11,206 patients to develop a predictive model, which was validated using a subsequent cohort of 3,523 patients., Results: In the model development cohort, alcohol was detected in the blood of 3,180 BAC-tested patients (28.7%), of whom 91.2% had a BAC + 50 status. Preliminary analysis revealed associations between a BAC + 50 status and sex, age, race, injury type (intentional vs. unintentional), and time of injury (night vs. day and weekend vs. weekday). A predictive model using four attributes (sex and injury type) identified patients at low, medium, and high risk for being BAC + 50. The model was validated using the second group of patients., Conclusion: Injured patients with a high probability of being alcohol positive can be identified using a simple scoring system based on readily available demographic and clinical information.

Objective: A prospective study of the interaction between airbag (AB) and seat-belt (Bt) protection versus vehicular compartment (VC) intrusion effects on injury patterns in motor vehicle crash (MVC) trauma patients., Methods: Two hundred MVC patients, nonejected drivers or front seat passengers with multiple trauma or severe lower extremity (LE) trauma admitted to two Level I trauma centers., Results: In frontal crashes, airbags (AB) more than Bt reduced Glasgow Coma Scale severity in brain injury, face fracture, shock, and the need for MVC extrication (all p < 0.05). Frontal AB also had a protective effect on LE fractures (41% vs. 66%, p < 0.01), but had no significant protective effect on pelvic fractures. When AB protection was present, it prevented brain and face fracture injuries caused by impact contacts and reduced the incidence of these injuries resulting from VC intrusions (p < 0.05). Thoracoabdominal injuries resulting from steering wheel intrusion showed AB protection against intrusions of twice the magnitude of those seen in non-AB vehicles (p < 0.05). In frontal MVCs, AB reduced LE fracture contact injuries but did not prevent LE fractures resulting from intrusions of instrument panel, toepan, or floor pedal structures. In lateral MVCs, Bt did not protect against brain, face, thorax, or pelvic injuries., Conclusions: Safety measures beyond frontal airbags must address frontal crash LE injuries induced by steering wheel, instrument panel, and toepan passenger compartment structure intrusions. Lateral crash injuries may profit from side AB supplemental restraint protection.

Bicycling is the leading cause of recreational injury, resulting in more than half a million emergency department visits and about 900 deaths each year in the United States. Previous research on bicycling injury was conducted predominantly in children and focused on the effectiveness of safety helmets. Few studies have examined the role of alcohol in bicycling injuries. This study examined the magnitude of and factors related to alcohol involvement in fatal and nonfatal bicycling injuries, and tested the hypothesis that alcohol intoxication is associated with significantly increased likelihood of fatality given a serious bicycling injury. Medical examiner data on all fatally injured bicyclists aged 10 years or older from 1987 to 1994 in Maryland (fatal cases, n = 63) were compared with trauma registry data on all injured bicyclists who were treated at a regional trauma center during the same time period (nonfatal cases, n = 253) on variables related to blood alcohol concentrations (BACs), demographic characteristics, and injury circumstances. The fatal cases were more likely than the nonfatal cases to have positive BACs (30% vs. 16%, p < 0.01) and to be legally intoxicated (i.e., BACs > or = 0.10%) (22% vs. 13%, p < 0.01). For both fatal and nonfatal cases, intoxication was more prevalent among victims who were male, aged 20 to 39 years, or who were injured at nighttime (7:00 PM to 6:59 AM). Bicyclists who died at the scene were four times as likely as those who died at hospitals to be legally intoxicated (35% vs. 9%, p < 0.02). Given a serious bicycling injury, intoxication was associated with significantly increased likelihood of fatality, with an adjusted odds ratio of 2.8 (95% confidence interval, 1.3 to 6.3). This increased likelihood of fatality was probably due in part to the fact that the rate of helmet use at the time of injury among the intoxicated was much lower than among the sober (6% vs. 31%, p < 0.05). Results indicate that alcohol plays an important role in fatal and serious bicycling injuries. Preventing intoxicated biking should be incorporated into helmet campaigns and other bicycle safety programs.

Objective and Design: To determine the relationship between airbags and lower extremity injuries, 10 drivers admitted to a level-I trauma center with substantial lower extremity trauma incurred in crashes involving airbag-equipped vehicles were studied in depth with regard to their injuries, the circumstances of the crashes, and the medical charges for the acute management of those injuries., Materials and Methods: During the clinical investigation portion of this study, we photographed lower extremity injuries, both soft tissue and radiographs, and performed a detailed surgical exploration during the debridement of open wounds or fracture fixation to treat them appropriately and to define the mechanism of injury, the fracture pattern, the pattern of soft-tissue insult, and the extent of periosteal stripping. We recorded the hospital and professional charges associated with the acute management not only of these injuries, but of the other injuries as well. The analysis performed for each case included a detailed crash reconstruction, including force, contact point, and vehicle intrusion data. Particular attention was paid to the dashboard and toe pan areas to determine deformation and intrusion and their association with thigh, leg, and foot injuries. Pertinent deformation and trajectory information was entered into the Calspan Reconstruction of Accident Speeds on the Highway (CRASH) computer program to generate a delta V or change in velocity measurement used as a measure of collision severity. When field data were incompatible with the limitations of the CRASH program, manual calculations such as "slide to stop" and conservation of momentum formulas were used., Results: The seven male and three female drivers had a mean age of 39.4 years. Only four used seatbelt restraints. The mean delta V was 28.3 mph and the mean maximum crush was 32.4 inches. The mean Injury Severity Score of 13.2. Musculoskeletal injuries included 11 foot/ankle fractures, 6 tibial fractures, 2 patellar fractures, 6 femoral fractures, and two acetabular/pelvic fractures. Other trauma included abdominal, thoracic, head and upper torso injuries, it seems that these safety devices do not prevent injuries to the lower extremity.

Objective: To develop a statistically valid method for trauma reimbursement and quality assurance (QA) length-of-stay filters. This is needed because diagnosis related group (DRG)-based trauma payment systems assume a random sampling of injury severities from a normally distributed population and thus result in economic disincentives to level I trauma centers., Methods: 142 trauma patients with MVC blunt multisystem injuries (MSI) (ISS > or = 16) were studied concurrently during their hospital course., Setting: Level I regional trauma center., Outcome Measures: Outcome measures were (dependent variables) length of stay (LOS) and state-approved hospital charges (COST)., Results: Mean acute care COST was $74,310, but the distribution of COST was log normal, rather than Gaussian normal as assumed by DRGs. The LOS for MSI was more than twice the average for all trauma (22 vs. 9 days), reflecting skewed severities of level I patients and was related to COST (r2 = 0.802; p < 0.0001). The ISS alone was a weak determinant of COST or LOS (r2 = 0.05; p < 0.0001). The best single determinant of COST and LOS was survival (r2 = 0.15; p < 0.0001): as it increased, it increased LOS. The most costly injuries (all p < 0.0001) involved the lower extremity (LE) or hip joint (HIP), whereas sepsis and pulmonary and surgical complications constituted the most costly complications (all p < 0.0001). Regression models that accounted for the log-normal distribution of the dependent variable and based on binary variables for survival, LE and HIP injuries, and the complications of sepsis, ARDS, pulmonary failure, MOFS, plus ISS, explained nearly two thirds of the variability in COST (r2 = 0.621; p < 0.0001) or LOS (r2 = 0.687; p < 0.0001) and the residuals were normally distributed., Conclusions: These models provide a valid method of reimbursement for MSI trauma for level I trauma centers, since the data imply that good care associated with survival from specific complications of MSI are the major determinants of COST, rather than the specific type of injury or the resultant ISS. Moreover, using survival and ISS plus the disease-related complications as determinants of LOS, this method can be applied to any U.S. region since local factors can be used to adjust hospital COST as a highly correlated function of LOS. This method also permits identification of LOS outliers for QA, taking into account the influence of injury complications.

Prospective and contemporaneous medical and economic cost studies of 144 victims of motor vehicle crashes admitted to a regional level I trauma center with multiple injuries (ISS > or = 16) revealed 122 non-ejected patients, of whom 102 required extrication (EXTRIC) from the vehicle for physical or medical reasons and 20 who did not (N group). There were no differences in age (EXTRIC, 34 +/- 17 years; N, 41 +/- 24 years), type of crash (Frontal: 57% EXTRIC, 60% N; Lateral: 32% EXTRIC, 35% N) restraint use (35% EXTRIC, 35% N), or mortality (29% EXTRIC, 30% N). However, the estimated maximum speed before the crash was higher in EXTRIC patients (50 +/- 16 mph vs. 46 +/- 18 mph N, p < 0.04), as was the change in velocity (delta V) on impact (EXTRIC 30 +/- 15 mph; N, 24 +/- 8 mph, p < 0.01). Brain injuries (51% EXTRIC vs. 35% N) and lower extremity injuries were more numerous in EXTRIC patients (59% vs. 20% N, p < 0.003) and the number of splenic, lower extremity, and pelvic injuries associated with shock was greater in EXTRIC patients, p < 0.02; as were postinjury complications. As a result, operating room costs from orthopedic and plastic surgery increased professional charges in the EXTRIC group versus the N group ($20,000, EXTRIC; $17,000, N) and critical care costs ($13,000, EXTRIC; $4,000, N) with total costs of $72,000 and $77,000, respectively. The lower extremity injuries in EXTRIC patients were primarily a result of body part contacts with intrusions (CIs) of the car occupant compartment structures [73% with vs. 24% without (p < 0.0001)]. In lateral MVCs, brain injuries were also more commonly associated with CIs of the side window frame or A pillar (72% CI vs. 25% no CI; p < 0.035); but as a whole in MVCs in which extrication was necessary, lower extremity injuries from instrument panel or toepan CIs appeared more frequent than those resulting from contacts only (p < 0.0001). In EXTRIC patients, 69% of those in shock had CI injuries, and 80% of the deaths in the EXTRIC group were associated with CI injury. These data suggest that measures designed to prevent CIs by strengthening car passenger compartment structures may reduce the incidence of severe brain and lower extremity injuries and may reduce the need for extrication after MVCs.

Clinical data on the nature and severity of injuries was linked with data from police crash reports for 3675 car or truck drivers admitted to trauma centers. Different patterns of injuries were noted for drivers in frontal compared with left lateral collisions. Injuries to the face and lower extremities were significantly greater in frontal collisions; thorax, abdominal, and pelvic injuries were significantly greater in lateral collisions. In addition, drivers in lateral collisions were found to have significantly more multiple injuries to the abdomen and thorax. Despite no difference in mean injury Severity Score, drivers in left lateral collisions had a significantly higher mortality rate; moreover, this increased mortality was not merely a reflection of the increased incidence of lateral collisions among older drivers. In conclusion, information on direction of impact has potential use for clinical decision making, since drivers in lateral collisions have a higher incidence of occult abdominal and thoracic injuries.

A comprehensive study was conducted of all motorcycle traffic crashes occurring in Maryland during a one-year period. All available medical and cost data were linked with police crash reports. During the study period, 1,900 motorcycle drivers were involved in crashes. The data indicated that (i) helmet usage was 35% overall, 30% among fatally injured drivers, and only 16% among drivers with a history of drug/alcohol conviction, (ii) unhelmeted drivers seen at an emergency department were almost twice as likely to have sustained head injury (40%) as were helmeted drivers (21%) (the corresponding percentages for hospitalized drivers were 55% and 38%), and (iii) acute care cost for unhelmeted drivers was three times ($30,365) that of helmeted drivers.

Introduction: The practice of assessing only trauma patients with elevated blood alcohol concentrations (BACs) or positive drug screens for psychoactive substance use disorders (PSUDs) was evaluated., Methods: Twenty-four BAC-negative (BAC-) (BAC, 0) and 21 BAC-positive (BAC+) (BAC, greater than or equal to 22 mmol/L or 100 mg/dL; mean, 41 mmol/L; range, 24.3 to 79 mmol/L) adult trauma patients were evaluated for alcoholism and other PSUDs using the Structured Clinical Interview (SCI) from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R). Approximately half were vehicular crash victims and 78% were men., Results: A total of 64 PSUDs were diagnosed in 31 (68.9%) of the 45 patients; all but one was for dependence (vs abuse). Of the BAC+ patients, 14 (66.7%) met DSM-III-R criteria for alcohol dependence, 11 (78.6%) of whom also had other PSUDs not related to alcohol. Two other BAC+ patients had nonalcohol PSUDs. Of the BAC- patients, 11 (45.8%) had alcohol dependence, six (54.5%) of whom also had nonalcohol PSUDs. Another four BAC- patients had nonalcohol PSUDs. Overall, 76.2% of the BAC+ patients and 62.5% of the BAC- patients had a diagnosis of psychoactive substance dependence., Conclusion: All patients admitted to trauma centers should be assessed for alcoholism and other PSUDs.

The culpability, crash-related traffic convictions, and pre- and post-crash driving records of a group of injured impaired (blood alcohol level greater than 80 mg/dl) drivers (N = 58) who were admitted to a Level I trauma center were compared with a group of admitted unimpaired drivers (N = 92). Both groups of drivers were 21 years of age or older, sustained moderate injuries (defined as having no injury of the brain, spinal column or cord, extremity, or pelvis with an Abbreviated Injury Score of greater than 2), and were discharged home. In the 140 crashes in which culpability was clearly defined, the impaired drivers caused a significantly greater percentage of their crashes (92.7%) compared to unimpaired (64.7%) drivers (p less than 0.001). Of the 55 unimpaired drivers who were considered culpable of causing their crashes, 12.7% received a traffic conviction compared with 39.2% of the 51 culpable impaired drivers. The mean number of total pre-crash traffic violations was higher for impaired drivers than for unimpaired drivers (p less than 0.01). While the mean number of total post-crash convictions for unimpaired and impaired was not significantly different, the mean number of pre- and post-crash alcohol convictions was significantly higher for impaired drivers compared to unimpaired drivers (p less than 0.02). The data suggest that injury protects from legal prosecution and does not alter impaired driving practices.