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PubMed1992

Death certification and coding for ischaemic heart disease in Tasmania.

Official records show that the rates of mortality from ischaemic heart disease (IHD) in Tasmania have been the highest of all the Australian states for most of the past decade. This study assesses the accuracy of the official Tasmanian mortality data for IHD in 1987 and 1988 for males aged 25 to 74 years using routinely available clinical and pathological data supplemented by information from the attending doctor. Our findings show that a death officially coded to ICD 9 rubrics 410-414 (IHD) in Tasmania has 94% sensitivity and a positive predictive value of 90% for fatal definite acute myocardial infarction or possible coronary death as defined by the WHO. Comparison of our results with those of two earlier studies undertaken in Australian mainland centres indicates that differences in the official statistics for coronary mortality between Tasmania and the mainland states reflect true differences in the risk of coronary death. While the results from three Australian studies suggest that the routine system of death certification is reasonably accurate, careful monitoring of death certification and coding practices need to be undertaken regularly in all states of Australia if secular changes in regional patterns of coronary mortality are to be regarded as credible.

Adult↗
PubMed2005

The impact of diabetes in patients with necrotizing soft tissue infections.

BACKGROUND: Given the association of diabetes with necrotizing soft tissue infections (NSTIs) and hyperglycemia with mortality in critically ill patients, this study investigates the impact of diabetes and hyperglycemia in NSTI patients. METHODS: This is a retrospective review of NSTI patients at LBJ General Hospital between January 1995 and December 2002, assessing infectious morbidity, mortality, and length of hospital stay. RESULTS: There was a trend towards increased infectious complications, defined as a hospital-acquired (not present within 48 h of presentation) infection at a secondary site, amongst diabetic patients (RR 2.1, 95% CI 0.7-6.8) and patients with admission hyperglycemia greater than 200 mg/dL (OR 1.9, 95% CI 0.7-5.7) but not with admission hyperglycemia greater than 120 mg/dL (OR 1.6, 95% CI 0.3-8.7). Patients with an infectious complication had a longer hospital stay (median, interquartile range [IQR]; 36, 30-44 days vs. 10, 7-20 days, p < 0.001), increased mortality (29% vs. 7%, p = 0.05), and poorer outcome defined as death, amputation, or hospital stay exceeding the 75th percentile for length of stay (79% vs. 20%, p < 0.001). CONCLUSIONS: Diabetes mellitus and admission hyperglycemia may increase infectious complications in NSTI patients, predicting a longer and more complicated hospital course. Further study is required to define the optimal metabolic target in this patient population.

Adult↗
PubMed1998

Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in Victoria, Australia. Consultative Committee on Road Traffic Fatalities in Victoria.

OBJECTIVES: Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria, Australia, has identified problems including those contributing to death and the potential preventability of deaths in road fatalities who survived until at least the arrival of ambulance services. The present analysis examines the outcomes at a Level I trauma center compared with other hospital groups in Victoria. METHODS: Between 1992 and 1994, 257 consecutive eligible fatalities were evaluated. Problems in management and preventable deaths were identified at the trauma center (TC) and in pooled data from other hospital groups, i.e., specialist teaching (Level II), other metropolitan (Level III), large regional (Level III), and small regional hospitals. RESULTS: Mean problems identified and those contributing to death (controlled for the number of areas of care), were less frequent at TC (1.7 and 0.6) than at other hospital groups (specialist teaching, 1.9 and 1.1*; metropolitan, 3.1* and 1.6*; large regional, 3.8* and 1.8*; small regional, 5.1* and 2.6*) (*p < 0.05 compared with TC). Preventable and potentially preventable deaths were also less common at TC (20%) than at the other hospital groups (specialist teaching, 40%*; metropolitan, 41%*; large regional, 53%*; small regional, 62%*) (*p < 0.05 compared with TC). When a Trauma and Injury Severity Score of 75% or more was used to define preventable death, a similar trend was identified. CONCLUSION: Management of patients with major trauma at a Level I trauma center was associated with fewer problems contributing to death and fewer preventable and potentially preventable deaths than at the different hospital groups. A trauma system in Victoria, including bypass of major trauma patients to designated hospitals with 24-hour trauma services, is likely to decrease the frequency of problems, including the preventable death rates.

Accidents, Traffic↗
PubMed2001

Calcium antagonists for ischemic stroke: a systematic review.

BACKGROUND AND PURPOSE: Stroke is a common disease, and many trials with calcium antagonists as possible neuroprotective agents have been conducted. The aim of this review is to determine whether calcium antagonists reduce the risk of death or dependency after acute ischemic stroke. METHODS: Acute stroke trials were identified with help of the Cochrane Collaboration Stroke Group and personal contacts. All randomized trials (published and unpublished) investigating a calcium antagonist (acting on voltage-sensitive calcium channels) were included. Poor outcome, defined as death or dependency in activities of daily living, was used as main outcome. Analyses were, if possible, "intention-to-treat"; pooled relative risks with 95% CIs were calculated. RESULTS: Forty-seven trials were identified, of which 29 were included (7665 patients). No effect of calcium antagonists on poor outcome at the end of follow-up (relative risk, 1.04; 95% CI, 0.98 to 1.09) or on death at end of follow-up (relative risk, 1.07; 95% CI, 0.98 to 1.17) was found. Sensitivity analyses on route of administration and time interval between stroke and start of treatment showed no effect on outcome. In subgroups of unpublished and methodologically sound trials, a statistically significant negative effect for calcium antagonists was found. This contrasts with results of published trials and trials of moderate or poor methodological quality. CONCLUSIONS: The presented evidence rules out a clinically important effect of calcium antagonists after ischemic stroke. The large amount of data leads to narrow CIs with no significant heterogeneity, and the overall results are therefore likely to be statistically robust.

Brain Ischemia↗
PubMed1990

Impact of AIDS on mortality in San Francisco, 1979-1986.

We used death certificate data for San Francisco residents from 1979 to 1986 to calculate the number of deaths and years of potential life lost before age 65 (YPLL) for leading causes of death. Acquired immune deficiency syndrome (AIDS)-related deaths were defined as including cytomegalovirus infection (ICD-9 078.5); cryptococcal infection (ICD-9 117.5); Pneumocystis carinii pneumonia (ICD-9 136.3); other malignant neoplasms of the skin, site unspecified (ICD-9 173.9); deficiency of cell-mediated immunity (ICD-9 279.1); and unspecified immunity deficiency (ICD-9 279.3). These deaths increased from 5 (0.1% of all deaths) in 1979 to 534 (6.6%) in 1986. Of the 1,225 deaths caused by AIDS-related diseases during this period, 1,032 (84%) occurred in men aged 20-49 years. AIDS-related deaths increased between 1979 and 1986 from 0 to 44 (25% of all deaths), 0 to 257 (44%), and 0 to 150 (35%) in men aged 20-29 years, 30-39 years, and 40-49 years, respectively. In 1986, AIDS-related diseases were the third leading cause of deaths and the leading cause of YPLL among male San Francisco residents.

Acquired Immunodeficiency Syndrome↗
PubMed2006

Does informed consent exempt Japanese doctors from reporting therapeutic deaths?

The Japanese Medical Act section 21 states that doctors must report unnatural deaths to the police, even though the term "unnatural death" is not defined by law. However, many doctors are reluctant to report potential therapeutic deaths (PTDs). The Japanese Society of Legal Medicine has submitted guidelines for unnatural death, including PTD. These define a PTD as an unexpected death, the cause of which is unknown, but which is potentially related to medical practice. Such deaths are "reportable" to the coroner in the UK. In this study, we addressed the question of whether physicians would report each of eight hypothetical PTDs. Although the clinical societies (the Japan Society of Internal Medicine and the Japan Surgical Society) declare that doctors must report deaths due to gross negligence, 60% of the participants said that they would not report gross negligence involving an overdose in cases where they had obtained informed consent or had provided an explanation after the death occurred. This can be accounted for by the mistaken belief on the part of the participants that obtaining informed consent exempts Japanese physicians from the duty of reporting PTDs. The attitude of Japanese physicians is caused by the death investigation system, which is designed to discover whether a crime has been committed rather than focusing on the cause of death. Accordingly, the Japanese Government has decided to commission a pilot study from an independent organisation in which medical specialists will investigate PTDs in order to prevent deaths occurring as a result of gross negligence.

Accidental Falls↗
PubMed2003

Status epilepticus in Hong Kong Chinese: aetiology, outcome and predictors of death and morbidity.

The majority of patients with epilepsy live in developing countries but there is limited information on status epilepticus (SE) from these regions. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with SE. Patients with SE were ascertained from the medical, intensive care and emergency departments of a large urban hospital from 1996 to 2001. Factors for poor outcome, defined as death or morbidity as measured by deterioration in functional status using the Glasgow Outcome Score were analysed in a multivariate logistic regression model. A total of 107 episodes of SE occurring in Chinese patients were studied. The three most common underlying causes were cerebrovascular disease, metabolic derangement and anti-convulsant withdrawal but alcohol-related SE was infrequent. Twenty-six percent had worsened functional ability and the mortality rate was 16%. Predictors of poor outcome were older age (odds ratio (OR)=1.04, 95% CI 1.01-1.07), delay in treatment (OR=3.52, 95%CI 1.01-12.18), SE due to cerebrovascular disease (OR=9.73, 95% CI 1.58-59.96) and CNS infection (OR=30.27, 95% CI 3.14-292.19).

Adult↗
PubMed2003

Prospective study of sudden cardiac death among women in the United States.

BACKGROUND: There are few data regarding the determinants of sudden cardiac death (SCD) in women, primarily because of their markedly lower rate of SCD compared with men. Nonetheless, existing data, although sparse, suggest possible gender differences in risk factors for SCD. METHODS AND RESULTS: In this prospective cohort of 121 701 women aged 30 to 55 years at baseline, SCD was defined as death within 1 hour of symptom onset. From 1976 to 1998, 244 SCDs were identified. Although the risk of SCD increased markedly with age, the percentage of cardiac deaths that were sudden decreased. Most (69%) women who suffered a SCD had no history of cardiac disease before their death. However, almost all of the women who died suddenly (94%) had reported at least 1 coronary heart disease risk factor. Smoking, hypertension, and diabetes conferred markedly elevated (2.5- to 4.0-fold) risk of SCD, similar to that conferred by a history of nonfatal myocardial infarction (relative risk, 4.1; 95% confidence interval, 2.9 to 6.7). Family history of myocardial infarction before age 60 years and obesity were associated with moderate (1.6-fold) elevations in risk. With regard to mechanism, 88% of SCDs were classified as arrhythmic. In 76% of these, the first rhythm documented was ventricular tachycardia or ventricular fibrillation. CONCLUSIONS: These prospective data suggest that, as in men, coronary heart disease risk factors predict risk of SCD in women and that SCD is usually an arrhythmic death. Therefore, prevention of atherosclerosis or ventricular arrhythmias may reduce the incidence of SCD in women.

Adult↗
PubMed2003

Delayed repletion of O6-methylguanine-DNA methyltransferase resulting in failure to protect the human glioblastoma cell line SF767 from temozolomide-induced cytotoxicity.

OBJECT: Temozolomide (TMZ)-induced O6-methylguanine (MG) DNA lesions, if not removed by MG-DNA methyltransferase (MGMT), mispair with thymine, trigger rounds of futile mismatch repair (MMR), and in glioma cells lead to prolonged G2-M arrest and ultimately cell death. Depletion of MGMT by O6-benzylguanine (BG) sensitizes tumor cells to TMZ, and this combination is currently used in clinical trials. The use of the TMZ+BG combination in gliomas, however, is complicated by the prolonged TMZ-induced G2-M arrest, which may delay activation of poorly defined cell death pathways and allow for MGMT repletion and reversal of toxicity. METHODS: To address these issues, the actions of TMZ were monitored in DNA MMR-proficient SF767 glioma cells depleted of MGMT by BG, and in cells in which BG was removed at various times after TMZ exposure. In MGMT-depleted cells, TMZ exposure led to DNA single-strand breaks and phosphorylation of cdc2, followed by G2-M arrest, induction of p53/p21, and DNA double-strand breaks. Although DNA single-strand breaks, phosphorylation of cdc2, and G2-M arrest could be reversed by repletion of MGMT up to 5 days after TMZ exposure, TMZ-induced cytotoxicity could only be prevented if MGMT was replenished within 24 hours of the onset of G2-M arrest, and before the creation of DNA double-strand breaks. CONCLUSIONS: These results indicate that although SF767 glioma cells undergo a prolonged G2-M arrest in response to TMZ, their ability to escape TMZ-induced cytotoxicity by MGMT repletion is limited to an approximately 24-hour period after the onset of G2-M arrest.

Antineoplastic Agents↗
PubMedDate not supplied

Risk of fatal and near-fatal asthma in relation to inhaled corticosteroid use.

OBJECTIVE: To examine the relationship between patterns of use of inhaled beclomethasone dipropionate and the risk of fatal and near-fatal asthma. DESIGN: Nested case-control analysis of a historical cohort; a further analysis. SETTING: The 12,301 residents of Saskatchewan aged 5 to 54 years who were dispensed 10 or more asthma drugs from 1978 to 1987. PATIENTS: The 129 persons who experienced asthma death (n = 44) and near-death (n = 85) and their 655 controls matched as to age and date of entry into the cohort, with the additional matching criteria of at least one hospitalization for asthma in the prior 2 years, region of residence, and having received social assistance. MAIN OUTCOME: Life-threatening attacks of asthma defined as death due to asthma or the occurrence of hypercarbia, intubation, and mechanical ventilation during an acute attack of asthma. RESULTS: After accounting for the risk associated with use of other medications and adjustment for markers of risk of adverse events related to asthma, subjects who had been dispensed, on average, one or more metered-dose inhalers of beclomethasone per month over a 1-year period had a significantly lower risk of fatal and near-fatal asthma (odds ratio, 0.1; 95% confidence interval, 0.02 to 0.6). CONCLUSION: These data support recent guidelines from several countries that recommend the use of inhaled corticosteroids in moderate and severe asthma.

Administration, Inhalation↗
PubMed1994

Drug-related deaths between 1985 and 1992 examined at the Institute of Forensic Medicine in Vienna, Austria.

Considering the official figure on drug-related deaths in Austria, the problem of substance abuse has dramatically worsened over the last years. There is a distinct lack of comprehensive information concerning drug-related deaths in Austria, although deaths of drug users may be potentially important indicators of the extent of drug-related problems in the population. The results of examinations performed on 372 deceased substance abusers at the Institute of Forensic Medicine in Vienna between 1985 and 1992 are presented. Drug-related deaths are defined according to the official definition issued by the Austrian Federal Ministry of Internal Affairs. A distinction was made between injecting drug users and non-injecting drug users with respect to infectious diseases transmitted by sharing of paraphernalia. Between 1985 and 1992 there was a distinct increase in drug-related deaths. In approximately 30% an accidental single substance intoxication, mainly due to morphine, was found. A connection with a better quality of street drugs is assumed but not proven. In 207 corpses more than one drug, including alcohol, was detected. During the investigation there was an evident trend towards multi-substance abuse patterns. Furthermore, blood alcohol concentration, an additional risk factor for narcotic overdose, was strongly associated with higher age. The small number of examined drug injectors found positive for the human immunodeficiency virus type-1 (HIV-1) makes it difficult to draw any kind of conclusion regarding the HIV-I seroprevalence among injecting drug users in Vienna.

Adolescent↗
PubMed1999

Perioperative mortality and major cardio-pulmonary complications after lung surgery for non-small cell carcinoma.

OBJECTIVES: A database of patients operated of lung cancer was analyzed to evaluate the predictive risk factors of operative deaths and life-threatening cardiopulmonary complications. METHODS: From 1990 to 1997, data were collected concerning 634 consecutive patients undergoing lung resection for non-small cell carcinoma in an academic medical centre and a regional hospital. Operations were managed by a team of experienced surgeons, anaesthesiologists and chest physicians. Operative mortality was defined as death within 30 days of operation and/or intra-hospital death. Respiratory failure, myocardial infarct, heart failure, pulmonary embolism and stroke were considered as major non-fatal complications. Preoperative risk factors, extent of surgery, pTNM staging, perioperative mortality and major cardiopulmonary complications were recorded and evaluated using chi-square statistics and multivariate logistic regression. RESULTS: Complete data were obtained in 621 cases. The overall operative mortality was 3.2% (n = 19). Cardiovascular complications (n = 10), haemorrhage (n = 4) and sepsis or acute lung injury (n = 5) were incriminated as the main causative factors. In addition, there were 13 life-threatening complications (2.1%) consisting in strokes (n = 4), myocardial infarcts (n = 5), pulmonary embolisms (n = 1), acute lung injury (n = 1) and respiratory failure (n = 2). Four independent predictors of operative death were identified: pneumonectomy, evidence of coronary artery disease (CAD), ASA class 3 or 4 and period 1990-93. In addition, the risk of major complications was increased in hypertensive patients and in those belonging to ASA class 3 or 4. A trend towards improved outcome was observed during the second period, from 1994 to 97. CONCLUSION: Our data demonstrate that perioperative mortality is mainly dependent on the extent of surgery, the presence of CAD and provision of adequate medical and nursing care. Preoperative testing and interventions to reduce the cardiovascular risk factors may help to further improve perioperative outcome.

Adenocarcinoma↗
PubMed2002

Alcohol-related deaths contribute to socioeconomic differentials in mortality in Sweden.

BACKGROUND: This study aims at estimating the contribution of alcohol to socioeconomic mortality differentials in Sweden. METHODS: Data were obtained from a Census-linked Deaths Registry. Participants in the 1980 and 1990 censuses were included with a follow-up of mortality 1990-1995. Socioeconomic status was assigned from occupation in 1990 or 1980. Alcohol-related deaths were defined from underlying or contributory causes. Poison regressions were applied to compute age-adjusted mortality rate ratios for all-causes, alcohol-related and other causes among 30-79-year-olds. The contribution of alcohol to mortality differentials was calculated from absolute differences. RESULTS: Around 5% (9,547) of all deaths were alcohol-related (30-79 years). For both sexes, manual workers, lower nonmanuals, entrepreneurs and unclassifiable groups had significantly higher alcohol-related mortality than did upper nonmanuals. Male farmers had significantly lower such mortality. The contribution of alcohol to excess mortality over that of upper nonmanuals was greatest among middle-aged (40-59 years) men who were manual workers or who belonged to a group of 'unclassifiable & others' (25-35%). It was of considerable size also for middle-aged lower nonmanuals (both sexes), male entrepreneurs, female manual workers and 'unclassifiable & others'. Among men, the total contribution of alcohol (30-79 years) was estimated at 16% for manual workers, 10% for lower nonmanuals and 7% for entrepreneurs; and among women, 6% (manual workers, lower nonmanuals) and 3% (entrepreneurs). CONCLUSION: Although deaths related to alcohol were probably underreported (e.g. accidents), alcohol clearly contributes to socioeconomic mortality differentials in Sweden. The size of this contribution depends strongly on age (peak among the middle-aged) and gender (greatest among men).

Adult↗
PubMed1995

[Neuronal cell death and intracellular proteinase functions].

Recently, attention has been paid to intracellular proteinase functions in relation to the process of neuronal cell death, and defining how they are involved is essential for developing neuroprotective strategies as well as for understanding the pathology of neurodegenerative diseases. Several recent articles have outlined the activation and deleterious effect of mu-calpain, a calcium-activated cysteine proteinase, on the cytoskeleton protein network, which is thought to lead to cell death. Furthermore, a marked increase in cathepsins B, L, and D, lysosomal proteinases, and cathepsin E, non-lysosomal aspartic proteinase, in neurons has been shown in the early stage of neuronal degeneration. The increased levels of these lysosomal cathepsins in degenerating neurons are considered to be associated with stimulated autophagy, which occasionally can lead to neuronal cell death. The molecular form of cathepsin E accumulated in affected neurons was different from that of the normal cathepsin E molecule. This unusual molecular form of cathepsin E is likely to be critical for disruption of normal cellular function, possibly culminating in neuronal cell death. The increased level of such proteinases was also found in reactive glial cells. In these cells, cathepsin E was increased as a mature form exclusively in reactive microglial cells, while cathepsins D and G were increased mainly in reactive astrocytes. Overproduction of cathepsins E, D and G in these reactive glial cells may be finally involved in the pathogenesis of neuro-degenerative disease.

Animals↗
PubMed1963

PERINATAL MORTALITY AND SURVIVAL. II. COMPARISONS BETWEEN POPULATION GROUPS.

If the time span of risk of perinatal death is defined as the period from 20 weeks gestation through 27 days after birth, 97 out of 100 infants born in California during 1959 were born alive and survived the first month of life. The California State Department of Public Health made an analysis of descriptive items from 358,388 birth and 10,916 death certificates to identify demographic characteristics associated with perinatal mortality and survival. Maturity of the infant was the single most important factor; two-thirds of all perinatal mortality was among infants weighing 2,500 grams or less. An infant premature by any two of three criteria (birth weight, birth length or gestation) had less chance of surviving than an infant premature by only one; infants premature by all three measures had the poorest prospect of being born alive and surviving one month. Nonwhite premature infants fared better than white; Oriental infants of all weights showed remarkable survival capacity. Female infants of all races had a survival advantage over males up to weights of 4,501 grams or more.Certain "high-risk" groups of infants were identified: Infants premature by more than one criterion, Negro infants, infants who were one of a set of twins or triplets, infants born to older mothers or to very young multiparae, infants of mothers with four or more previous live births, those born by cesarean section, infants of families in low income occupations, infants of military personnel, infants born in county or federal hospitals, those born outside a hospital, those born to mothers who had no prenatal care and those born in northern, mountain counties.

Asian People↗
PubMed2006

The compound 13-D selectively induces apoptosis in white blood cancers versus other cancer cell types.

As general cytotoxins are still the backbone of anticancer chemotherapy, the identification of selective inducers of cell death in defined cancer types and subtypes is one of the major goals of modern oncology research. Thus, compounds identified with such selectivity have utility as probes of cancer-type-specific biological pathways, and optimized versions have potential in targeted anticancer therapy. Described herein is the discovery that compound 13-D selectively induces apoptotic cell death in white blood cancer cell lines but not in other cancer cell lines. Further experiments indicate that this selectivity is not simply due to selective cell permeability. The compound localizes to both the nucleus and cytoplasm and arrests cells in the prophase/prometaphase of the cell cycle, and there is a very sharp dependence of activity on compound structure, with the trans-alpha,beta-unsaturated amide of 13-D being critical for inducing cell death. The macromolecular target of 13-D could be involved in white blood cell-specific oncogenic pathways.

Antineoplastic Agents↗
PubMed2001

Preclinical syndromes predict dementia: the Sydney older persons study.

OBJECTIVES: To identify if preclinical syndromes for Alzheimer's disease, vascular dementia, and Parkinson's disease and related dementias exist. Identification of dementia at early or even preclinical stages has important implications for treatment. METHODS: A community dwelling sample of 647 subjects aged 75 and over at recruitment were followed up for a mean period of 3.19 years (range 2.61 to 4.51 years). Each subject was asked to participate in a medical assessment which included a standardised medical history examining both past and current health and medication usage; a neuropsychological battery (mini mental state examination, Reid memory test, verbal fluency, subsets of the Boston naming test and similarities, clock drawing and copied drawings) and physical examination. Preclinical syndromes for the three predominant dementias (Alzheimer's disease, vascular dementia and Parkinson's disease, and related dementias) and their combinations were defined using cognitive, motor, and vascular features. Their longitudinal outcome as defined by death and dementia incidence was examined. RESULTS: Preclinical syndromes affected 55.7% (n=299) of subjects. Preclinical syndromes showed a trend for an increased odds of death (odds ratio 1.72, p=0.056) and a significantly increased odds of developing dementia (odds ratio 4.81, p<0.001). Preclinical syndromes were highly sensitive, detecting 52 of 58 (89.7%) incident dementias. Two hundred and sixteen of 268 (80.6%) preclinical subjects did not show dementia over the 3 year period (positive predictive value 19.4%). Subjects defined as having a combination of cognitive, extrapyramidal, and vascular features were at greatest risk of progressing to dementia. CONCLUSIONS: Preclinical syndromes were sensitive and significant predictors of dementia. In view of their poor positive predictive value, the preclinical syndromes as defined in this study remain a research tool needing both definitional refinement and greater periods of observation. Multiple coexistent preclinical disorders resulted in a greater incidence of dementia, providing evidence for an additive role between multiple disorders.

Aged↗
PubMed1999

Trauma care regionalization: a process-outcome evaluation.

BACKGROUND: Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients. METHODS: This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III). RESULTS: A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers. CONCLUSION: This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Adult↗