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Publications (14)29.95 Total impact

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    ABSTRACT: 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-). 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. 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-. These data add strength to the premise that untreated substance abuse-related injury remains an untapped injury prevention opportunity.
    The Journal of trauma 12/2001; 51(5):877-84; discussion 884-6. DOI:10.1097/00005373-200111000-00009 · 2.96 Impact Factor
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    ABSTRACT: 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. 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. 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. 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.
    The Journal of trauma 09/2001; 51(3):557-64. DOI:10.1097/00005373-200109000-00024 · 2.96 Impact Factor
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    ABSTRACT: The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was self-limited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.
    The Journal of trauma 05/2000; 48(4):613-21; discussion 621-3. DOI:10.1097/00005373-200004000-00006 · 2.96 Impact Factor
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    ABSTRACT: Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (< or = 24 hours after admission) (n = 147) versus delayed fixation (> 24 hours after admission) (n = 24). Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.
    The Journal of trauma 05/1999; 46(5):839-46. · 2.96 Impact Factor
  • The Journal of Trauma Injury Infection and Critical Care 01/1999; 47(1). DOI:10.1097/00005373-199907000-00074
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    ABSTRACT: Background: Recent reports suggest that early fracture fixation worsens central nervous system (CNS) outcomes. We compared discharge Glasgow Coma Scale (GCS) scores, CNS complications, and mortality of severely injured adults with head injuries and pelvic/lower extremity fractures treated with early versus delayed fixation. Methods: Using trauma registry data, records meeting preselected inclusion criteria from the years 1991 to 1995 were examined. We identified 171 patients aged 14 to 65 years (mean age, 32.7 years) with head injuries and fractures who underwent early fixation (<or=to24 hours after admission) (n = 147) versus delayed fixation (>24 hours after admission) (n = 24). Results: Patients were severely injured, with a mean admission GCS score of 9.1, Revised Trauma Score of 6.2, Injury Severity Score of 38, median intensive care unit length of stay of 16.5 days, and hospital length of stay of 23 days. No differences between groups were found by age, admission GCS score, Injury Severity Score, Revised Trauma Score, intensive care unit length of stay, hospital length of stay, shock, vasopressors, major nonorthopedic operative procedures, total intravenous fluids or blood products, or mortality rates. In survivors, no differences in discharge GCS scores or CNS complications were found. Conclusion: We found no evidence to suggest that early fracture fixation negatively influences CNS outcomes or mortality.
    The Journal of Trauma Injury Infection and Critical Care 01/1999; 46(5):839-846. DOI:10.1097/00005373-199905000-00012
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    ABSTRACT: Objectives: To determine and compare the mortality rates of patients with bilateral versus unilateral femoral fractures and to determine the contribution of the femoral fracture to, and identify risk factors for, such mortality. Study Design: Retrospective analysis using trauma registry data on consecutive blunt trauma patients with unilateral (800 patients, group I) or bilateral (eighty-five patients, group II) femoral fractures. Methods: Univariate data analysis was performed to compare the groups' ages, Injury Severity Scores, Glasgow Coma Scale values, mortality, and the presence of adult respiratory distress syndrome (ARDS). Logistic regression analysis was performed to determine variables statistically associated with mortality. Results: Group II patients had a significantly higher Injury Severity Score (30.2 versus 24.5, p < 0.001), lower Glasgow Coma Scale value (12.3 versus 13.1, p = 0.05), higher mortality rate (25.9 vs 11.7%, p < 0.001), and higher incidence of ARDS (15.7 versus 7.27%, p = 0.014) than group I patients. Group II patients also had significantly more closed head injuries, open skull fractures, intraabdominal injuries requiring surgical intervention, and pelvic fractures; the rates of thoracic injury were similar. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures and death; however, other factors (shock, closed head injury, and thoracic injury) had much stronger correlations with mortality. Conclusions: Patients with bilateral femoral fractures have a significantly higher risk of death, ARDS, and associated injuries than patients with unilateral femoral fractures. This increase in mortality is more closely related to associated injuries and physiologic parameters than to the presence of bilateral femoral fractures. The presence of bilateral femoral fractures should alert the clinician to the likelihood of associated injuries, a higher Injury Severity Score, and the potential for a more serious prognosis.
    Journal of Orthopaedic Trauma 06/1998; 12(5):315-319. DOI:10.1097/00005131-199806000-00003 · 1.54 Impact Factor
  • The Journal of Trauma Injury Infection and Critical Care 01/1998; 44(2). DOI:10.1097/00005373-199802000-00072
  • Critical Care Medicine 12/1993; 22(1):A73. DOI:10.1097/00003246-199401000-00134 · 6.15 Impact Factor
  • Journal of Orthopaedic Trauma 12/1992; 6(4):488. DOI:10.1097/00005131-199212000-00038 · 1.54 Impact Factor
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    ABSTRACT: The records of obese and nonobese victims of blunt trauma were compared to determine if obese individuals are predisposed to a specific injury pattern. Prospectively collected data on 6368 adults admitted to a level I trauma center over a 4-year period were analyzed. Twelve percent (743 patients) met Body Mass Index (weight/height2) criteria for obesity (greater than or equal to 30 kg/m2). The obese group was older (p less than 0.01) and had lower ISSs (p less than 0.05) and higher GCS scores (p less than 0.01). More obese patients were injured in vehicular crashes (62.7% vs. 54.1% [p less than 0.01]). The obese victims were more likely to have rib fractures, pulmonary contusions, pelvic fractures, and extremity fractures and less likely to have incurred head trauma and liver injuries (p less than 0.05). Obese people injured in vehicular crashes had a similar injury pattern with no difference in seating position, direction of impact, seat belt use, and ejection.
    The Journal of trauma 09/1992; 33(2):228-32. DOI:10.1097/00005373-199208000-00011 · 2.96 Impact Factor
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    ABSTRACT: Improvement in trauma management requires a better understanding of the effect of a patient's preinjury health status on outcome. Specific historical findings and laboratory criteria were used to define pre-existing disease (PED) states and determine if they were independent predictors of fate in trauma victims. Of 7,798 adult patients admitted to a level I trauma center from July 1986 through June 1990, 16.0% (1,246) had greater than or equal to 1 PED. The PED+ and PED- patients had no significant difference in Injury Severity Scores (ISSs) (15.7 versus 15.6) and admission Glasgow Coma Scale (GCS) scores (13.9 versus 13.8). The PED+ patients were older (49.2 versus 30.6 years) (p less than 0.001) and had a higher mortality rate (9.2% versus 3.2%) (p less than 0.001) than PED- patients. Mortality rates were also elevated for patients with greater than or equal to 2 PEDs (18%) and for those with renal disease (38%), malignancy (20%), and cardiac disease (18%) (p less than 0.001) compared with PED- patients. Controlling for age and ISS, there was an association between PED and mortality (Mantel-Haenszel p less than 0.03). Multivariate regression showed that PED is an independent predictor of mortality (R2 = 0.1918; p less than 0.0001). The greatest increases in mortality were found among patients less than 55 years and with ISS less than 20. Changes in prehospital triage criteria and outcome scoring are needed. Improvements in the management of trauma victims with chronic disease may decrease their mortality rate.
    The Journal of trauma 03/1992; 32(2):236-43; discussion 243-4. · 2.96 Impact Factor
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    ABSTRACT: Improvement in trauma management requires a better understanding of the effect of a patient's preinjury health status on outcome. Specific historical findings and laboratory criteria were used to define pre-existing disease (PED) states and determine if they were independent predictors of fate in trauma victims. Of 7,798 adult patients admitted to a level I trauma center from July 1986 through June 1990, 16.0% (1,246) had >=1 PED. The PED+ and PED-patients had no significant difference in Injury Severity Scores (ISSs) (15.7 versus 15.6) and admission Glasgow Coma Scale (GCS) scores (13.9 versus 13.8). The PED+ patients were older (49.2 versus 30.6 years) (p < 0.001) and had a higher mortality rate (9.2% versus 3.2%) (p < 0.001) than PED-patients. Mortality rates were also elevated for patients with >=2 PEDs (18%) and for those with renal disease (38%), malignancy (20%), and cardiac disease (18%) (p < 0.001) compared with PED- patients. Controlling for age and ISS, there was an association between PED and mortality (Mantel-Haenszel p < 0.03). Multivariate regression showed that PED is an independent predictor of mortality (R2 = 0.1918; p < 0.0001). The greatest increases in mortality were found among patients <55 years and with ISS <20. Changes in prehospital triage criteria and outcome scoring are needed. Improvements in the management of trauma victims with chronic disease may decrease their mortality rate.
    The Journal of trauma 02/1992; 32(2):236. DOI:10.1097/00005373-199202000-00021 · 2.96 Impact Factor
  • The Journal of Trauma Injury Infection and Critical Care 01/1991; 31(7). DOI:10.1097/00005373-199107000-00076