While the association of pelvic fracture with sexual dysfunction is well known, most of the data pertains to men. How women are counseled about sexual health issues after pelvic trauma and how they interact with the healthcare system remains unknown. To describe the prevalence and spectrum of sexual health issues in women after pelvic fracture, and to identify factors associated with obtaining care for these concerns. Women treated for traumatic pelvic fractures at a single level 1 trauma center over a 5-year period were invited to participate in an online cross-sectional survey. Sexual health concerns and care-seeking behaviors were examined. Inverse probability weighting was utilized to adjust for nonresponse based on common variables within the trauma registry. All proportions presented are of weighted data unless otherwise stated. 98 of the 780 potential subjects responded to the survey (12.6% crude response rate). After weighting, 71% of responders were white and 42% had private insurance, with a mean age at the time of injury of 42.2 (SD 22.4) years and median time since injury of 45 (IQR 30.0, 57.4) months. Overall, 49.5% reported that sexual function was important to very important to their quality of life, with an additional 25.3% stating it was moderately important. While 17.1% (95% CI 8.4 – 26.0%) of women reported some pre-injury sexual health concerns, 59.0% (95% CI 47.1 – 71.0%) reported post-injury sexual dysfunction. Specific complaints included genital pain (17.8%), difficulty with orgasm (26.0%), difficulty with sexual desire (31.3%), dyspareunia (37.1%), genital numbness (7.5%), difficulty with arousal or lubrication (9.6%), and difficulty with sexual satisfaction (34.4%). 30.4% of women with post-injury sexual dysfunction reported resolution without treatment (18.2% within 6 months, 36.4% between 6-12 months, and 45.5% after 1 year). An additional 15.4% stated that they continue to have concerns and desire treatment, with only 11.6% stating they have received treatment. The remaining 42.6% continue to report sexual dysfunction but do not view treatment as a health priority. Overall, 26.4% of all responders recalled having sexual health discussions after injury, with 87.5% of these conversations being patient-initiated. Of those with post-injury sexual dysfunction, 60.8% had sexual health discussions with providers, 83.3% of which were patient-initiated. Only white race and rural residence were significantly associated with occurrence of sexual health discussions (p<0.001). The most common reasons for patients not raising the topic of sexual health with providers among those with sexual dysfunction were embarrassment/fear (23.6%), assuming the issue would resolve with time (23.5%), feeling the topic was inappropriate (17.2%), lack of information about condition/available treatments (19.9%) and sexual health not being a health priority (22.4%).

OBJECTIVE:To determine if any of five different state gun laws were associated with firearm mortality: (1) "shall issue" laws permitting an individual to carry a concealed weapon unless restricted by another statute; (2) a minimum age of 21 years for handgun purchase; (3) a minimum age of 21 years for private handgun possession; (4) one gun a month laws which restrict handgun purchase frequency; and (5) junk gun laws which ban the sale of certain cheaply constructed handguns.DESIGN:A cross sectional time series study of firearm mortality from 1979 to 1998.SETTING:All 50 states and the District of Columbia.SUBJECTS:All residents of the United States.MAIN OUTCOME MEASURES:Firearm homicides, all homicides, firearm suicides, and all suicides.RESULTS:When a "shall issue" law was present, the rate of firearm homicides was greater, RR 1.11 (95% confidence interval 0.99 to 1.24), than when the law was not present, as was the rate of all homicides, RR 1.08 (95% CI 0.98 to 1.17), although this was not statistically significant. No law was associated with a statistically significant decrease in the rates of firearm homicides or total homicides. No law was associated with a statistically significant change in firearm suicide rates.CONCLUSION:A "shall issue" law that eliminates most restrictions on carrying a concealed weapon may be associated with increased firearm homicide rates. No law was associated with a statistically significant reduction in firearm homicide or suicide rates.

CONTEXTAlthough posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders.OBJECTIVEWe tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse.DESIGNRandomized effectiveness trial.PARTICIPANTSWe recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center.INTERVENTIONPatients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury.MAIN OUTCOME MEASURESWe used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury.RESULTSRandom-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P =.01) and alcohol abuse/dependence (P =.048). The CC group demonstrated no difference (-0.07%; 95% confidence interval [CI], -4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of -24.2% (95% CI, -19.9% to -28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year.CONCLUSIONSEarly mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Though the rate has significantly decreased, the United States continued into the late 90's with one of the highest fire death rates in the industrialized world. Given the advancements in fire prevention, including public education, building design, consumer product safety, and sophisticated levels of the fire protection in this country, it is puzzling to many as to why this is so. In an effort to identify the underlying problem(s), researchers have been delving deeper into the extent to which human behavior affects our fire losses. The connection between alcohol and the ignition, detection, and escape from the fire has been broadly examined by numerous medical and fire protection organization studies. A series of landmark studies undertaken by the Johns Hopkins University and the National Bureau of Standards in the 1970's were among the first to discover a definitive link between alcohol consumption and fire deaths. Many studies have now confirmed their general findings. Alcohol intoxication may increase the risk of initiating a fire by impairing one's judgment and coordination. An intoxicated individual who is smoking may also succumb to the depressant effects of alcohol, fall asleep and drop a lit cigarette on upholstery or clothing. Intoxication also acutely diminishes one's ability to detect a fire. Under the sedative effects of alcohol, an alcohol-impaired person may fail to notice the smell of smoke, or fail to hear a smoke alarm. Escape from a fire can be hampered by the loss of motor coordination and mental clarity caused by alcohol, even when warning signs are heeded. Furthermore, burns are more physiologically damaging in the presence of alcohol. Several researchers have found that about half of all adult fire fatalities were under the influence of alcohol at the time of the fire. Men have been found to consistently outnumber women among fire casualties and do so with even greater disparity for fire victims under the influence of alcohol. In addition, the younger adult population (ages 15 to 34) seems to incur the greatest number of alcohol-impaired fire casualties. Drinking behaviors that are characteristic of various age groups and sexes may explain these findings. 2 Studies have also provided conclusive evidence supporting the deleterious effects of chronic and acute alcohol abuse on the occurrence and recovery from burn injuries. Burn injury victims have been found to be disproportionately likely to have been intoxicated at the time of injury or known to be heavy drinkers. …

Background: To improve reinjury prevention strategies targeting hazardous drinking, we determined its predictors and longitudinal course in the year after injury.Methods: This was a prospective study of 101 randomly selected hospitalized trauma patients who before injury represented the full range of substance abuse, from severe to none. We hypothesized that clinical data obtained routinely by trauma centers would predict hazardous drinking during the postinjury year.Results: Drug and alcohol use dropped markedly 1 month after injury but returned to preinjury levels by 4 months. Forty-one percent of the sample drank hazardously before injury, and 55% drank hazardously after. From before to after injury, 20% of patients worsened their hazardous drinking status, and only 6% of patients improved it. Three clinical predictors of hazardous drinking during the year were identified: any positive blood alcohol concentration > 0 at admission (odds ratio [OR], 9.18; 95% confidence interval [CI], 2.51-33.56), any days > 0 of using nonprescription drugs of abuse in the month before injury (OR, 6.63; 95% CI, 1.76-25.04), and suffering an intentional injury (OR, 5.1; 95% CI, 1.38-18.77).Conclusion: Efforts to reduce hazardous drinking after injury should target patients with this risk profile and focus on the 1- to 4-month period after injury hospitalization.

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.

Data on research participants and populations frequently include race, ethnicity, and gender as categorical variables, with the assumption that these variables exert their effects through innate or genetically determined biologic mechanisms. There is a growing body of research that suggests, however, that these variables have strong social dimensions that influence health. Socioeconomic status, a complicated construct in its own right, interacts with and confounds analyses of race/ethnicity and gender. The Academy recommends that research studies include race/ethnicity, gender, and socioeconomic status as explanatory variables only when data relevant to the underlying social mechanisms have been collected and included in the analyses.

Background: The relationship between facial fractures and traumatic brain injury is controversial. Some studies show an increased risk of brain injury with the presence of facial fractures while others claim that facial fractures protect against brain injury.Objective: To examine the association between facial fractures and traumatic brain injuries.Design: Case-control study.Setting: Subjects were recruited from the emergency departments of 7 hospitals in the Seattle, Wash, area.Patients: Three thousand eight hundred forty-nine injured bicyclists and 5 scene deaths were identified from March 1, 1992, to August 31, 1994, with complete data available on 3388 bicyclists.Interventions: None.Results: The study group was composed of 1602 cases with injuries to the head, face, or brain and 1540 control subjects. There were 203 bicyclists with traumatic brain injuries, of whom 62 had an identifiable intracranial injury and 141 suffered a concussion. A total of 81 patients sustained facial fractures. The odds ratio for the risk of intracranial injury associated with facial fractures after adjustment for significant confounders was 9.9 (95% confidence interval, 5.1-19.3). The effect was less strong but still present when all traumatic brain injuries including concussions were considered (odds ratio, 2;95% confidence interval, 1.1-3.7). No association was found for concussion only.Conclusions: This study demonstrates no evidence that facial fractures help prevent traumatic brain injury. Data indicate that facial fractures are markers for increased risk of brain injury.

Study objective: To describe the experience of an emergency medical services system with the use of liberal indications for prehospital pediatric endotracheal intubation.Methods: We performed a retrospective review of prehospital and hospital patient records in an urban and suburban prehospital care system. The study included ail children aged 15 years or younger who were intubated in the prehospital setting by King County paramedics from January 1, 1984, to December 31, 1990.Results: During the 7-year study period, 654 children were intubated, of which 355 (54%) were study patients. The median age of the patients was 3 years; 60% had an injury diagnosis. On arrival of the paramedics, 60% of the patients were in sinus rhythm, 62% had a systolic blood pressure of 70 mm Hg or greater, and 56% had a respiratory rate of 10 breaths per minute or greater. The Glasgow Coma-Scale score was 8 or lower in 83% of the patients. Succinyicholine was used to facilitate intubation in 47% of patients. On arrival at the emergency department, 79% of the patients were in sinus rhythm; 75% had an adequate blood pressure (70 mm Hg or greater); 86% had a Pao, Value of 100 mm Hg or greater; and 74% had a Paco(2) value of 45 mm Hg or lower. Complications of intubation, more than half of which were classified as minor, were noted in 22.6% of patients. We were unable to determine the number of failed intubation attempts. Most of the patients (58%)survived to hospital discharge. Among cardiac arrest victims, only 12% survived.Conclusion: In a setting where paramedics practice with close medical direction,applying liberal indications for pediatric intubation and permitting the use of succinylcholine allowed paramedics to intubate children of different ages and diagnoses.

To better elucidate the incidence, nature, and consequences of transportation related injuries in a developing urban area, we undertook an epidemiologic survey in Kumasi, Ghana 656 (5.6%) of 11,663 persons surveyed had sustained an injury in the preceding year. Transportation related mechanisms accounted for 16% of these injuries, but were more severe than other mechanisms in terms of length of disability and cost of treatment. The majority of injuries were either to passengers involved in crashes of mini-buses or taxis (29%) or to pedestrians struck by these vehicles (21%). Prevention strategies may need to be fundamentally different from those of developed nations and need to target professional drivers more than private road users.

OBJECTIVES:The incidence, type, severity, and costs of crash-related injuries requiring hospitalization or resulting in death were compared for helmeted and unhelmeted motorcyclists.METHODS:This was a retrospective cohort study of injured motorcyclists in Washington State in 1989. Motorcycle crash data were linked to statewide hospitalization and death data.RESULTS:The 2090 crashes included in this study resulted in 409 hospitalizations (20%) and 59 fatalities (28%). Although unhelmeted motorcyclists were only slightly more likely to be hospitalized overall, they were more severely injured, nearly three times more likely to have been head injured, and nearly four times more likely to have been severely or critically head injured than helmeted riders. Unhelmeted riders were also more likely to be readmitted to a hospital for follow-up treatment and to die from their injuries. The average hospital stay for unhelmeted motorcyclists was longer, and cost more per case; the cost of hospitalization for unhelmeted motorcyclists was 60% more overall ($3.5 vs $2.2 million).CONCLUSIONS:Helmet use is strongly associated with reduced probability and severity of injury, reduced economic impact, and a reduction in motorcyclist deaths.

S OF PAPERS TO BE PRESENTED AT THE FIFTY-FOURTH ANNUAL SESSION: AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA Sheraton Harbor Island, San Diego, California: PDF Only

To investigate whether tobacco, alcohol, and their combined use are important risk factors for fire injuries, the authors analyzed data from a population-based case-control study in King County, Washington, between 1986 and 1987. Cases (n = 116) were households with at least one fatal or nonfatal unintentional residential fire injury reported to the Washington State Fire Incident Reporting System from 1984 through 1985. Controls were selected by random digit dialing (n = 256). After adjustment for household size, number of male household members, total household income, and education of the head of the household, the odds ratio for fire injury in households whose members collectively smoked 1-9 cigarettes per day was 1.5 (95% confidence interval (CI) 0.6-4.2) relative to households with no smokers; for 10-19 cigarettes per day, the odds ratio was 6.6 (95% CI 2.5-17.5), and for 20 or more cigarettes per day, it was 3.6 (95% CI 1.9-7.2). Although households with alcohol drinkers who consumed five or more drinks per occasion were found to be at increased risk in the crude analysis, multivariate analysis suggested that this was partly because drinkers tended to live in households with higher smoking levels. Thus, even though households with alcohol drinkers who consume five or more drinks per occasion may be at increased risk of residential fire injury, smoking appears to be the more important underlying risk factor.

The effort to increase the use of child safety seats (CSS) over the last decade has been an outstanding success in the field of childhood injury control. This article describes that effort and discusses lessons which can be learned and applied to other injury control problems. These include choosing a specific important problem and addressing it with a particular solution, developing a critical mass of community awareness through broad-based grass roots support, legislation, efforts of primary care physicians, and eventual institutionalization of the program.