Faculty Bibliography

Alcohol use is a risk factor for severe injury in pedestrians struck by motor vehicles. Our objective was to investigate alcohol use by bicyclists and its effects on riding behaviors, medical management, injury severity, and mortality within a congested urban setting. A hospital-based, observational study of injured bicyclists presenting to a Level I regional trauma center in New York City was conducted. Data were collected prospectively from 2012 to 2014 by interviewing all bicyclists presenting within 24 h of injury and supplemented with medical record review. Variables included demographic characteristics, scene-related data, Glasgow Coma Scale (GCS), computed tomography (CT) scans, and clinical outcomes. Alcohol use at the time of injury was determined by history or blood alcohol level (BAL) >0.01 g/dL. Of 689 bicyclists, 585 (84.9%) were male with a mean age of 35.2. One hundred four (15.1%) bicyclists had consumed alcohol prior to injury. Alcohol use was inversely associated with helmet use (16.5% [9.9-25.1] vs. 43.2% [39.1-47.3]). Alcohol-consuming bicyclists were more likely to fall from their bicycles (42.0% [32.2-52.3] vs. 24.2% [20.8-27.9]) and less likely to be injured by collision with a motor vehicle (52.0% [41.7-62.1] vs. 67.5% [63.5-71.3]). 80% of alcohol-consuming bicyclists underwent CT imaging at presentation compared with 51.5% of non-users. Mortality was higher among injured bicyclists who had used alcohol (2.9% [0.6-8.2] vs. 0.0% [0.0-0.6]). Adjusted multivariable analysis revealed that alcohol use was independently associated with more severe injury (Adjusted Odds Ratio 2.27, p = 0.001, 95% Confidence Interval 1.40-3.68). Within a dense urban environment, alcohol use by bicyclists was associated with more severe injury, greater hospital resource use, and higher mortality. As bicycling continues to increase in popularity internationally, it is important to heighten awareness about the risks and consequences of bicycling while under the influence of alcohol.

INTRODUCTION: Falls from heights are an important cause of unintentional fatal injury. We investigated the relationship between the characteristics of fatal falls and resulting injury patterns. MATERIALS AND METHODS: We reviewed prospectively collected data from the Office of Chief Medical Examiner in New York City between 2000 and 2010. Data included fall height, work or non-work related, use of safety equipment, intentionality, specific organ injuries, and death on impact. The primary outcome was organ injury based on fall height. RESULTS: Higher falls were associated with hemorrhage as well as rib and various organ injuries. Organ injury pattern did not differ based on work status. The presence of equipment misuse or malfunction was associated with more deaths upon impact. Victims of falls from 200 ft or higher were 11.59 times more likely to die on impact than from lower than 25 ft. CONCLUSIONS: Fall height and work-related falls were significantly associated with death on impact. This is a public health issue, as 13% of falls were work related and 4% of falls were due to improper use of safety equipment. Some work-related falls are potentially preventable with proper safety equipment use. Understanding patterns of injury may play a role in prevention and management of survivors in the acute period.

Object/UNASSIGNED:The purpose of the current study is to determine the sensitivity and specificity of an eye tracking method as a classifier for identifying concussion. Methods/UNASSIGNED:Brain injured and control subjects prospectively underwent both eye tracking and Sport Concussion Assessment Tool 3. The results of eye tracking biomarker based classifier models were then validated against a dataset of individuals not used in building a model. The area under the curve (AUC) of receiver operating characteristics was examined. Results/UNASSIGNED:An optimal classifier based on best subset had an AUC of 0.878, and a cross-validated AUC of 0.852 in CT- subjects and an AUC of 0.831 in a validation dataset. The optimal misclassification rate in an external dataset (n = 254) was 13%. Conclusion/UNASSIGNED:If one defines concussion based on history, examination, radiographic and Sport Concussion Assessment Tool 3 criteria, it is possible to generate an eye tracking based biomarker that enables detection of concussion with reasonably high sensitivity and specificity.

We conducted individual and ecologic analyses of prospectively collected data from 839 injured bicyclists who collided with motorized vehicles and presented to Bellevue Hospital, an urban Level-1 trauma center in New York City, from December 2008 to August 2014. Variables included demographics, scene information, rider behaviors, bicycle route availability, and whether the collision occurred before the road segment was converted to a bicycle route. We used negative binomial modeling to assess the risk of injury occurrence following bicycle path or lane implementation. We dichotomized U.S. National Trauma Data Bank Injury Severity Scores (ISS) into none/mild (0-8) versus moderate, severe, or critical (>8) and used adjusted multivariable logistic regression to model the association of ISS with collision proximity to sharrows (i.e., bicycle lanes designated for sharing with cars), painted bicycle lanes, or physically protected paths. Negative binomial modeling of monthly counts, while adjusting for pedestrian activity, revealed that physically protected paths were associated with 23% fewer injuries. Painted bicycle lanes reduced injury risk by nearly 90% (IDR 0.09, 95% CI 0.02-0.33). Holding all else equal, compared to no bicycle route, a bicycle injury nearby sharrows was nearly twice as likely to be moderate, severe, or critical (adjusted odds ratio 1.94; 95% confidence interval (CI) 0.91-4.15). Painted bicycle lanes and physically protected paths were 1.52 (95% CI 0.85-2.71) and 1.66 (95% CI 0.85-3.22) times as likely to be associated with more than mild injury respectively.

BACKGROUND: New York City (NYC) has made significant roadway infrastructure improvements, initiated a bicycle share program, and enacted Vision Zero, an action plan to reduce traffic deaths and serious injuries. The objective of this study was to examine whether bicycle helmets offer a protective advantage against traumatic brain injury (TBI) within a contemporary dense urban setting with a commitment to road safety. METHODS: A prospective observational study of injured bicyclists presenting to a Level I trauma centre was performed. All bicyclists arriving within 24h of injury were included. Data were collected between February, 2012 and August, 2014 and included demographics, imaging studies (e.g. computed tomography (CT)), injury patterns, and outcomes including Glasgow Coma Scale (GCS) and Injury Severity Score. RESULTS: Of 699 patients, 273 (39.1%) were wearing helmets at the time of injury. Helmeted bicyclists were more likely to have a GCS of 15 (96.3% [95% Confidence Interval (CI), 93.3-98.2] vs. 87.6 [95% CI, 84.1-90.6]) at presentation. Helmeted bicyclists underwent fewer head CTs (40.3% [95% CI, 34.4-46.4] vs. 52.8% [95% CI, 48.0-57.6]) and were less likely to sustain intracranial injury (6.3% [95% CI, 2.6-12.5] vs. 19.7% [14.7-25.6]), including skull fracture (0.9% [95% CI, 0.0-4.9] vs. 15.3% [95% CI, 10.8-20.7]) and subdural hematoma (0.0% [95% CI, 0.0-3.2] vs. 8.1% [95% CI, 4.9-12.5]). Helmeted bicyclists were significantly less likely to sustain significant TBI, i.e. Head AIS >/=3 (2.6% [95% CI: 0.7-4.5] vs.10.6% [7.6-12.5]). Four patients underwent craniotomy while three died; all were un-helmeted. A multivariable logistic regression model showed that helmeted bicyclists were 72% less likely to sustain TBI compared with un-helmeted bicyclists (Adjusted Odds Ratio 0.28, 95% CI 0.12-0.61). CONCLUSIONS: Despite substantial road safety measures in NYC, the protective impact of simple bicycle helmets in the event of a crash remains significant. A re-assessment of helmet laws for urban bicyclists is advisable to most effectively translate Vision Zero from a political action plan to public safety reality.

Study Objectives: New York City (NYC) recently expanded its bicycle routes by demarcating bike lanes with paint and constructing 30 miles of protected paths that physically separate automobile traffic from bicyclists to address increases in bicyclist fatalities. Our objective was to determine whether bike lanes and protected paths result in safety benefits for bicyclists in NYC. We hypothesized that bike lanes would be associated with reduced injury severity among bicyclists colliding with motor vehicles and that protected paths would be associated with an even greater safety benefit. Methods: We performed a secondary analysis of bicyclist injury data collected from December 2008 to August 2014 at a Level 1 Trauma Center in NYC. We evaluated the association of protected paths and bike lanes on injury severity while controlling for potential confounders including patient demographics, scene-related and environmental information, helmet use, traffic law compliance, street characteristics, and injury mechanism. Data were obtained from patient interviews and medical records. Injury severity score (ISS) was categorized according to National Trauma Data Bank (NT

OBJECTIVES: We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City's (NYC's) central business district. METHODS: Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses. RESULTS: Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723). CONCLUSIONS: Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs. (Am J Public Health. Published online ahead of print August 13, 2015: e1-e6. doi:10.2105/AJPH.2015.302738).

BACKGROUND: The objective of this study was to characterize variations in packed red blood cell (PRBC) transfusion practices in critically ill patients and to identify which factors influence such practices. We hypothesized that significant variation in transfusion triggers exists among acute care surgeons. METHODS: A survey of PRBC transfusion practices was administered to the American Association for the Surgery of Trauma members. The scenarios examined hemoglobin thresholds for which participants would transfuse PRBCs. RESULTS: A hemoglobin threshold of less than or equal to 7 g/dL was adopted by 45% of respondents in gastrointestinal bleeding, 75% in penetrating trauma, 66% in sepsis, and 62% in blunt trauma. Acute care surgeons modified their transfusion trigger significantly in the majority of the modifications of these scenarios, often inappropriately so. CONCLUSIONS: This study documents continued evidence-practice gaps and wide variations in the PRBC transfusion practices of acute care surgeons. Numerous clinical factors altered such patterns despite a lack of supporting evidence (for or against).

Background: Mild traumatic brain injuries are frequently evaluated in EDs. Standardized concussion surveillance tools such as the SCAT 3 have been proposed. Developed as a post-injury tool for athletes, SCAT3 is routinely used in pre-injury, baseline assessment. Population-based normative data can aid in interpretation of individual variability or when baseline data are unavailable. To date, all SCAT3 data have been collected in the athlete population with an absence of data on non-athlete (N-A) controls or acutely injured nonathletes. Objectives: We investigate SCAT3 subcomponents in N-A healthy controls, corpus (non head-injured) trauma, and acutely head-injured patients presenting to the ED to derive reference values for novel populations. We hypothesize that trauma patients with suspected head injury will have worse SCAT3 metrics than uninjured controls. Methods: Target groups were extracted from a database of prospectively recruited patients. SCAT3/SAC (Standardized Assessment of Concussion) was administered at time of ED presentation or recruitment. Multi-sample comparisons were evaluated by the Kruskal- Wallis test; pairwise comparisons were analyzed by the Steel-Dwass procedure. Results: A comparison of SCAT3 subcomponents by patient group is seen in Table 732a. One hundred eleven N-A healthy controls, 121 bodily trauma not warranting head CT in ED, 242 head trauma with negative head CT findings, and 67 head trauma patients with positive head CT were evaluated. Control group comparison seen in Table 732b. In number of symptoms, symptom severity score, and SAC, there was a significant difference between control, corpus and - CT/+CT groups. In immediate memory and Balance Error Scoring System (BESS), there was a significant difference between control, corpus, and -CT/+CT, with corpus statistically similar to -CT/ +CT. In concentration, there was a significant difference between control, corpus, and -CT/+CT, with corpus similar to -CT. In orientation, there was a significant difference between control/corpus and -CT/+CT. Conclusion: In healthy, N-A controls, all SCAT3 values were significantly different from all trauma groups'. In -CT/+CT groups, all SCAT3 values were similar to each other. A graded effect was seen from control to corpus to head trauma. Diagnostic ranges of SCAT3 subcomponents vary in the N-A and bodily trauma population. (Table presented)