Comparison of single bicycle crashes and collisions among severely injured cyclists-A 16-year analysis based on the Helsinki Trauma Registry (HTR)

OBJECTIVE

The Finnish national Traffic Safety Strategy 2022-2026 seeks to halve the number of road fatalities and serious injuries from 2020 to 2030. The strategy states that better information on bicycle crashes is needed for safety promotion. The aim of this study was to describe the demographics, injury characteristics, alcohol involvement, and helmet use of severely injured cyclists and to compare single bicycle crashes (falling alone or hitting a fixed object) to collisions.

MATERIAL AND METHODS

We identified all bicycle crashes between 2006 and 2021 from the Helsinki Trauma Registry (HTR). Variables analysed were basic patient demographics, Abbreviated Injury Scale (AIS) codes, AIS 3+ injuries, injured body regions, patient Injury Severity Score (ISS) and New Injury Severity Score (NISS), 30-day in-hospital mortality, ICU length of stay, injury mechanism, alcohol use by the injured cyclists, and helmet use.

RESULTS

Of the 325 severe (NISS >15) cycling injury patients in the HTR, 53.5 % were injured in single crashes and 46.5 % in collisions with a moving object. Most (71.4 %) patients were men and mean age of all patients was 54.1 years (SD 16.7). Alcohol was detected in 23.1 % of cases and more often in single crashes (32.8 %) than in collisions (11.9 %). Less than a third (29.2 %) of all cyclists wore a helmet; those who wore a helmet had fewer serious (AIS 3+) head injuries than those who did not. Cyclists injured in collisions had higher ISS and NISS scores than those injured in single crashes. Serious (AIS 3+) injuries in extremities or in pelvic girdle were more common in collisions than in single crashes.

CONCLUSIONS

Among severely injured cyclists, single bicycle crashes were more common; alcohol was more often detected in single bicycle crashes than in collisions. Overall injury severity was higher in collisions than in single crashes. Helmet users had less AIS 3+ head injuries than non-users. Attention should be focused on preventing alcohol-related cycling injuries, promoting use of bicycle helmets, and more precise and comprehensive documentation of bicycle crashes in health care units.

Effects of the COVID-19 pandemic on trauma-related emergency medical service calls: a retrospective cohort study

Background

The COVID-19 pandemic has had profound effects on the utilization of health care services, including Emergency Medical Services (EMS). Social distancing measures taken to prevent the spread of the disease have greatly affected the functioning of societies and reduced or halted many activities with a risk of injury. The aim of this study was to report the effects of lockdown measures on trauma-related EMS calls in the Finnish capital area.

Methods

We conducted a retrospective cohort study of all EMS calls in the Helsinki University Hospital (HUH) catchment area between 1 January and 31 July 2020. Calls were identified from the HUH EMS database. Calls were grouped into pre-lockdown, lockdown, and post-lockdown periods according to the restrictions set by the Finnish government and compared to the mean number of calls for the corresponding periods in 2018 and 2019. Statistical comparisons were performed using Mann-Whitney U-test for weekly numbers and percentages.

Results

During the study period there was a total of 70,705 EMS calls, of which 14,998 (21.2%) were related to trauma; 67,973 patients (median age 61.6 years; IQR 35.3–78.6) were met by EMS. There was no significant change in the weekly number of total or trauma-related EMS calls during the pre-lockdown period. During the lockdown period, the number of weekly total EMS calls was reduced by 12.2% (p = 0.001) and the number of trauma-related calls was reduced by 23.3% (p = 0.004). The weekly number of injured patients met by EMS while intoxicated with alcohol was reduced by 41.8% (p = 0.002). During the post-lockdown period, the number of total and trauma-related calls and the number of injured patients intoxicated by alcohol returned to previous years’ levels.

Conclusions

The COVID-19 pandemic and social distancing measures reduced the number of trauma-related EMS calls. Lockdown measures had an especially significant effect on the number of injured patients intoxicated by alcohol met by the EMS.

Trial registration

Not applicable.

Trauma-registry survival outcome follow up: 30 days is mandatory and appears sufficient

INTRODUCTION

Thirty-day in-hospital mortality is a common outcome measure in trauma-registry research and benchmarking. However, this does not include deaths after hospital discharge before 30 days or late deaths beyond 30 days since the injury. To evaluate the reliability of this outcome measure, we assessed the timing and causes of death during the first year after major blunt trauma in patients treated at a single tertiary trauma center.

METHODS

We used the Helsinki Trauma Registry to identify severely injured (NISS ≥ 16) blunt trauma patients during 2006 to 2015. The Population Register center of Finland provided the mortality data for patients and Statistics Finland provided the cause of death information from death certificates. Disease, work-related disease, medical treatment, and unknown cause of death were considered as non-trauma related deaths. We divided the 1-year study period into the following three categories: in-hospital death before 30 days (Group 1), death after discharge but within 30 days (Group 2), and death 31 to 365 days since admission (Group 3).

RESULTS

We included 3557 patients with a median NISS of 29. Altogether, 21.8% (776/3557) patients died during the first year since the injury. Of these non-survivors, 12.7% (450) were in Group 1, 4.0% (141) in Group 2, and 5.2% (185) in Group 3. Non-traumatic deaths not directly related to the injury increased substantially as the time from the injury increased and were 2.0% (9/450) in Group 1, 13.5% (19/141) in Group 2, and 35.7% (66/185) in Group 3.

CONCLUSION

Thirty-day mortality is a proper outcome that measures survival after severe blunt trauma. However, applying only in-hospital mortality instead of actual 30-day mortality may exclude non-survivors who die at another facility before day 30. This could result in over-optimistic benchmarking results. On the other hand, extending the follow-up period beyond 30 days increases the rate of non-traumatic deaths. By combining data from different registries, it is possible to address this challenge in current trauma-registry research caused by lack of follow up.

Major blunt trauma causes increased mortality up to 12 years: Long-term survival in 3 557 patients compared to 35 502 control persons

BACKGROUND

Trauma registries usually report 30-day or in-hospital mortality as an outcome measure. However, some studies criticize this measure as inadequate; the impact of a major trauma could last longer than 1 month after the injury. We studied the long-term mortality of patients who sustained a major trauma.

METHODS

The Helsinki University Hospital's trauma registry was used for patient identification from 2006 to 2015 (New Injury Severity Score ≥ 16 and blunt mechanism of injury). For each trauma registry patient, 10 control persons matched by age, sex, and county of residency were obtained from the Population Register Center of Finland. Cause of death information was obtained from Statistics Finland.

RESULTS

We included 3 557 trauma registry patients and 35 502 control persons. Follow-up ranged from 1 year 7 months to 11 years 7 months. The 1-year mortality was 11 times higher in the trauma-patient group (22% vs. 2%). The long-term (approximately 12 years) mortality after the injury was 2.6 times higher in the trauma-patient group (46% vs. 18%). For patients surviving at least 1 year post-trauma, the mortality at 12 years was 2.2 times higher than in the control group (31% vs. 14 %). The cause of death was a disease in 73.3% of the trauma patients and 93.6% of the controls. Accidents were more often a cause of death in the patient population than in the control population (21.2% vs. 4.1%). Suicide was the cause of death in 3.0% of patients and 1.1% in controls. Several factors associated with increased mortality were identified.

CONCLUSIONS

Major trauma patients had significantly higher long-term mortality compared to controls. To the best of our knowledge, this is the first study on this subject with a follow up of this duration with patients this severely injured and a cohort this large.

How to Validate Data Quality in a Trauma Registry? The Helsinki Trauma Registry Internal Audit

BACKGROUND AND AIMS

Trauma registry data are used for analyzing and improving patient care, comparison of different units, and for research and administrative purposes. Data should therefore be reliable. The aim of this study was to audit the quality of the Helsinki Trauma Registry internally. We describe how to conduct a validation of a regional or national trauma registry and how to report the results in a readily comprehensible form.

MATERIALS AND METHODS

Trauma registry database of Helsinki Trauma Registry from year 2013 was re-evaluated. We assessed data quality in three different parts of the data input process: the process of including patients in the trauma registry (case completeness); the process of calculating Abbreviated Injury Scale (AIS) codes; and entering the patient variables in the trauma registry (data completeness, accuracy, and correctness). We calculated the case completeness results using raw agreement percentage and Cohen's κ value. Percentage and descriptive methods were used for the remaining calculations.

RESULTS

In total, 862 patients were evaluated; 853 were rated the same in the audit process resulting in a raw agreement percentage of 99%. Nine cases were missing from the registry, yielding a case completeness of 97.1% for the Helsinki Trauma Registry. For AIS code data, we analyzed 107 patients with severe thorax injury with 941 AIS codes. Completeness of codes was 99.0% (932/941), accuracy was 90.0% (841/932), and correctness was 97.5% (909/932). The data completeness of patient variables was 93.4% (3899/4174). Data completeness was 100% for 16 of 32 categories. Data accuracy was 94.6% (3690/3899) and data correctness was 97.2% (3789/3899).

CONCLUSION

The case completeness, data completeness, data accuracy, and data correctness of the Helsinki Trauma Registry are excellent. We recommend that these should be the variables included in a trauma registry validation process, and that the quality of trauma registry data should be systematically and regularly reviewed and reported.

Risk factors for early readmission due to surgical complications after treatment of proximal femoral fractures - A Finnish National Database study of 68,800 patients

INTRODUCTION

Hip fracture surgery is associated with a considerable amount medical and surgical complications, which adversely impacts the patient's outcome and/or increases costs. We evaluated what risk factors were associated with the occurrence of early readmission due to surgical complications after hip fracture surgery.

MATERIAL AND METHODS

A nationwide database with 68,800 hip fracture patients treated between 1999 and 2011 was studied to uncover the association of readmissions with co-morbidities, fracture types, different hospital types and treatment methods using the Cox proportional hazards model.

RESULTS

Early readmission within three months due to hip fracture surgery complications occurred at a rate of 4.6%. Increased occurrence of readmission was found among patients with: heavy alcoholism (HR 1.38; 95% CI: 1.23-1.53); Parkinson's disease (PD; HR 1.22; 95% CI: 1.05-1.42); pre-existing osteoarthritis (HR 2.02; 95% CI: 1.83-2.23); rheumatic disease (HR 1.44; 95% CI: 1.27-1.65); as well as those with a fracture of the femur neck, depression, presence of a psychotic disorder, an operative delay of at least three days, or previous treatment with total hip arthroplasty.

CONCLUSION

Our results indicate that there are several factors associated with an increased risk of early readmission. We suggest that in the presence of these factors, the surgical treatment method and postoperative protocol should be carefully planned and performed.

Resource use and clinical outcomes in blunt thoracic injury: a 10-year trauma registry comparison between southern Finland and Germany

PURPOSE

Serious thoracic injuries are associated with high mortality, morbidity, and costs. We compared patient populations, treatment, and survival of serious thoracic injuries in southern Finland and Germany.

METHODS

Mortality, patient characteristics and treatment modalities were compared over time (2006-2015) in all patients with Abbreviated Injury Scale (AIS) thorax ≥ 3, Injury Severity Score (ISS) > 15, age > 15 years, blunt trauma mechanism, and treatment in Intensive Care Unit (ICU) in Level 1 hospitals included in the Helsinki Trauma Registry (HTR) and the TraumaRegister DGU^® (TR-DGU).

RESULTS

We included 934 patients from HTR and 25 448 patients from TR-DGU. Pre-hospital differences were seen between HTR and TR-DGU; transportation in the presence of a physician in 61% vs. 97%, helicopter use in 2% vs. 42%, intubation in 31% vs. 55%, and thoracostomy in 6% vs. 10% of cases, respectively. The mean hospital length of stay (LOS) and ICU LOS was shorter in HTR vs. TR-DGU (13 vs. 25 days and 9 vs. 12 days, respectively). Our main outcome measure, standardised mortality ratio, was not statistically significantly different [1.01, 95% confidence interval (CI) 0.84-1.18; HTR and 0.97, 95% CI 0.94-1.00; TR-DGU].

CONCLUSIONS

Major differences were seen in pre-hospital resources and use of pre-hospital intubation and thoracostomy. In Germany, pre-hospital intubation, tube thoracostomy, and on-scene physicians were more prevalent, while patients stayed longer in ICU and in hospital compared to Finland. Despite these differences in resources and treatment modalities, the standardised mortality of these patients was not statistically different.

Sixfold Post-Fracture Mortality in 16- To 30-Year-Old Patients-Suicides, Homicides, and Intoxications Among Leading Causes of Death

BACKGROUND AND AIMS:

The death of any young individual is associated with the loss of many potentially fulfilling years of life. It has been suggested that the relative mortality of fracture patients may be higher in younger age groups than in older cohorts. We determined the mortality and causes of death in a cohort of 16- to 30-year-old patients that had been hospitalized for fractures.

MATERIAL AND METHODS:

We collected data using criteria based on the diagnosis code (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), surgical procedure code (Nordic Medico-Statistical Committee), and seven additional characteristics of patients admitted to the trauma ward at the Central Finland Hospital between 2002 and 2008. Patients were then followed to ascertain their mortality status until the end of 2012. Standardized mortality ratios were calculated and causes of death were determined by combining our registry data with data provided by Statistics Finland.

RESULTS:

During the study, 199 women and 525 men aged 16-30 years had sustained fractures. None of these patients died during the primary hospital stay. At the end of follow-up (mean duration 7.4 years), 6 women and 23 men had died. The standardized mortality ratio for all patients was 6.2 (95% Confidence Interval: 4.3-8.9). Suicides and intoxications comprised over half, and motor vehicle accidents and homicides comprised nearly a third of the post-fracture deaths.

CONCLUSION:

We found a concerning increase in mortality among young adults that had been hospitalized due to a fracture compared to the general population that had been standardized by age, sex, and calendar-period. Leading causes of death were suicides and intoxications or motor vehicle accidents and homicides, which may be indicative of depressive disorders or impulse control disorders, respectively. Identification of the underlying psychosocial problems may provide an opportunity for preventive interventions.

Accuracy and Coverage of Diagnosis and Procedural Coding of Severely Injured Patients in the Finnish Hospital Discharge Register: Comparison to Patient Files and the Helsinki Trauma Registry

Background and Aims:

The Finnish Hospital Discharge Register data are frequently used for research purposes. The Finnish Hospital Discharge Register has shown excellent validity in single injuries or disease groups, but no studies have assessed patients with multiple trauma diagnoses. We aimed to evaluate the accuracy and coverage of the Finnish Hospital Discharge Register but at the same time validate the data of the trauma registry of the Helsinki University Hospital’s Trauma Unit.

Materials and Methods:

We assessed the accuracy and coverage of the Finnish Hospital Discharge Register data by comparing them to the original patient files and trauma registry files from the trauma registry of the Helsinki University Hospital’s Trauma Unit. We identified a baseline cohort of patients with severe thorax injury from the trauma registry of the Helsinki University Hospital’s Trauma Unit of 2013 (sample of 107 patients). We hypothesized that the Finnish Hospital Discharge Register would lack valuable information about these patients.

Results:

Using patient files, we identified 965 trauma diagnoses in these 107 patients. From the Finnish Hospital Discharge Register, we identified 632 (65.5%) diagnoses and from the trauma registry of the Helsinki University Hospital’s Trauma Unit, 924 (95.8%) diagnoses. A total of 170 (17.6%) trauma diagnoses were missing from the Finnish Hospital Discharge Register data and 41 (4.2%) from the trauma registry of the Helsinki University Hospital’s Trauma Unit data. The coverage and accuracy of diagnoses in the Finnish Hospital Discharge Register were 65.5% (95% confidence interval: 62.5%–68.5%) and 73.8% (95% confidence interval: 70.4%–77.2%), respectively, and for the trauma registry of the Helsinki University Hospital’s Trauma Unit, 95.8% (95% confidence interval: 94.5%–97.0%) and 97.6% (95% confidence interval: 96.7%–98.6%), respectively. According to patient records, these patients were subjects in 249 operations. We identified 40 (16.1%) missing operation codes from the Finnish Hospital Discharge Register and 19 (7.6%) from the trauma registry of the Helsinki University Hospital’s Trauma Unit.

Conclusion:

The validity of the Finnish Hospital Discharge Register data is unsatisfactory in terms of the accuracy and coverage of diagnoses in patients with multiple trauma diagnoses. Procedural codes provide greater accuracy. We found the coverage and accuracy of the trauma registry of the Helsinki University Hospital’s Trauma Unit to be excellent. Therefore, a special trauma registry, such as the trauma registry of the Helsinki University Hospital’s Trauma Unit, provides much more accurate data and should be the preferred registry when extracting data for research or for administrative use, such as resource prioritizing.

Increased mortality after upper extremity fracture requiring inpatient care

BACKGROUND AND PURPOSE

Increased mortality after hip fracture is well documented. The mortality after hospitalization for upper extremity fracture is unknown, even though these are common injuries. Here we determined mortality after hospitalization for upper extremity fracture in patients aged ≥16 years.

PATIENTS AND METHODS

We collected data about the diagnosis code (ICD10), procedure code (NOMESCO), and 7 additional characteristics of 5,985 patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. During the study, 929 women and 753 men sustained an upper extremity fracture. The patients were followed up until the end of 2012. Mortality rates were calculated using data on the population at risk.

RESULTS

By the end of follow-up (mean duration 6 years), 179 women (19%) and 105 men (14%) had died. The standardized mortality ratio (SMR) for all patients was 1.5 (95% CI: 1.4-1.7). The SMR was higher for men (2.1, CI: 1.7-2.5) than for women (1.3, CI: 1.1-1.5) (p < 0.001). The SMR decreased with advancing age, and the mortality rate was highest for men with humerus fractures.

INTERPRETATION

In men, the risk of death related to proximal humerus fracture was even higher than that reported previously for hip fracture. Compared to the general population, the SMR was double for humerus fracture patients, whereas wrist fracture had no effect on mortality.

Incidence of fractures requiring inpatient care

BACKGROUND

The overall incidence of fractures has been addressed in several studies, but there are few data on different types of fractures that require inpatient care, even though they account for considerable healthcare costs. We determined the incidence of limb and spine fractures that required hospitalization in people aged ≥ 16 years.

PATIENTS AND METHODS

We collected data on the diagnosis (ICD10 code), procedure code (NOMESCO), and 9 additional characteristics of patients admitted to the trauma ward of Central Finland Hospital between 2002 and 2008. Incidence rates were calculated for all fractures using data on the population at risk.

RESULTS AND INTERPRETATION

During the study period, 3,277 women and 2,708 men sustained 3,750 and 3,030 fractures, respectively. The incidence of all fractures was 4.9 per 10(3) person years (95% CI: 4.8-5.0). The corresponding numbers for women and men were 5.3 (5.1-5.4) and 4.5 (4.3-4.6). Fractures of the hip, ankle, wrist, spine, and proximal humerus comprised two-thirds of all fractures requiring hospitalization. The proportion of ankle fractures (17%) and wrist fractures (9%) was equal to that of hip fractures (27%). Four-fifths of the hospitalized fracture patients were operated. In individuals aged < 60 years, fractures requiring hospitalization were twice as common in men as in women. In individuals ≥ 60 years of age, the opposite was true.

Cemented or uncemented hemiarthroplasty for the treatment of femoral neck fractures?

BACKGROUND AND PURPOSE

Cemented hemiarthroplasty is preferred in treating displaced fractures of the femoral neck in the elderly. The cementing process may cause a fat embolism, leading to serious complications or death. In this study, we wanted to determine whether use of uncemented hemiarthroplasty (HA) would lead to reduced mortality and whether there are differences in the complications associated with these different types of arthroplasty.

PATIENTS AND METHODS

From the PERFECT database, which combines information from various treatment registries, we identified 25,174 patients who were treated with hemiarthroplasty for a femoral neck fracture in the years 1999-2009. The primary outcome was mortality. Secondary outcomes were reoperations, complications, re-admissions, and treatment times.

RESULTS

Mortality was lower in the first postoperative days when uncemented HA was used. At 1 week, there was no significant difference in mortality (3.9% for cemented HA and 3.4% for uncemented HA; p = 0.09). This was also true after one year (26% for cemented HA and 27% for uncemented HA; p = 0.1). In patients treated with uncemented HA, there were significantly more mechanical complications (3.7% vs. 2.8%; p < 0.001), hip re-arthroplasties (1.7% vs. 0.95; p < 0.001), and femoral fracture operations (1.2% vs. 0.52%; p < 0.001) during the first 90 days after hip fracture surgery.

INTERPRETATION

From registry data, mortality appears to be similar for cemented and uncemented HA. However, uncemented HA is associated with more frequent mechanical complications and reoperations.

[Posterior dislocation of the sternoclavicular joint]

Posterior dislocation of the sternoclavicular joint is a rare injury. It can be associated with life-threatening complications. Computed tomography is the imaging modality of choice with which possible associated injuries can be detected. Acute injuries are managed with closed reduction under general anaesthesia. A fracture-dislocation is inherently more unstable than an isolated dislocation. Surgical treatment is advocated in cases of delayed diagnosis or failed closed reduction. With early diagnosis and treatment, the long-term outcome of this injury is good.

Validation of an HPLC method for the quantification of ambroxol hydrochloride and benzoic acid in a syrup as pharmaceutical form stress test for stability evaluation

A method is described for ambroxol, trans-4-(2-amino-3,5-dibromobenzylamino) cyclohexanol hydrochloride, and benzoic acid separation by HPLC with UV detection at 247 nm in a syrup as pharmaceutical presentation. Optimal conditions were: Column Symmetry Shield RPC8, 5 microm 250 x 4.6 mm, and methanol/(H(3)PO(4) 8.5 mM/triethylamine pH=2.8) 40:60 v/v. Validation was performed using standards and the pharmaceutical preparation which contains the compounds described above. Results from both standards and samples show suitable validation parameters. The pharmaceutical grade substances were tested by factors that could influence the chemical stability. These reaction mixtures were analysed to evaluate the capability of the method to separate degradation products. Degradation products did not interfere with the determination of the substances tested by the assay.

Direct measurement of homovanillic, vanillylmandelic and 5-hydroxyindoleacetic acids in urine by capillary electrophoresis

Separation conditions in CE, with a neutral coated capillary and reversed polarity, have been optimised to make direct measurement of vanillylmandelic acid, homovanillic acid and 5-hydroxyindoleacetic acid possible in urine samples without pre-treatment. The method developed has been validated, presenting adequate parameters for linearity, accuracy and precision. Detection limits range from 0.03 to 2.5 microM. Finally the method has been applied to urine samples taken from patients, both adults and children, in hospital. Some of them were also measured by immunoassay and HPLC-electrochemical detection and results have been compared.