Syncope and Motor Vehicle Crash Risk: A Danish Nationwide Study

The Journal of Emergency Medicine adequate, and 3 being adequate, present, and readily available. These ratings were compared using the Wilcoxon signed rank test between the 2014 and 2004 data for the hospitals that were assessed at both intervals. For district level (smaller) hospitals, the mean rating of availability increased from 0.8 to 1.3 from 2004 to 2014. The study specifically noted that diagnostic services markedly changed, but general surgical capabilities had a doubling in rating from 1 to 2. In regional (larger) hospitals, the mean rating increased from 1.1 to 1.4. These hospitals also saw the strongest increases in general surgery, with ratings increasing from 2 to 3 for major and basic general surgery over the 10 year period. The study noted that the three most common factors contributing to resource deficiencies were absence of items/never having the item available, lack of training, and items being out of stock when needed. The authors concluded that although there has been an overall trend to advancement of resources of trauma care available in the nation of Ghana in both regional and district level hospitals, there still remain significant deficiencies. They suggest that most often a lack of access/availability of equipment limited capacity and the investigators advocate for dedicated trauma funding to help reduce the burden of disease. [Robert Klemisch, MD Denver Health Medical Center, Denver, CO] Comment: This paper provides one of the few published comparisons of trauma resource availability in low and middle income countries. This research confirms that while progress is being made to address deficiencies in trauma care resources, there are still significant deficiencies that will require collaborative efforts to improve trauma care in underserved areas. , HELICOPTER TRANSPORT IMPROVES SURVIVAL FOLLOWING INJURY IN THE ABSENCE OF A TIME-SAVING ADVANTAGE. Brown J, Gestring M, Guyette F, et al. Surgery. 2016;159:947-959 Helicopter emergency medical services have demonstrated survival benefits over ground emergency medical services on the population level. Though helicopter transport offers the most obvious benefits in speed of transport, there are other advantages including availability of advanced interventions, highly experienced providers for critically ill patients, and enhnced trauma center access. This study was undertaken to evaluate if there was a survival benefit to helicopter transport independent of transfer speed. The study was a retrospective cohort study using the National Trauma Databank. As helicopter versus ground transport was not assigned randomly, the study used propensity score matching to match ground and helicopter transport subjects with similar transport times. Subjects were stratified based on 5 minute increments of transport time and a conditional logistic regression was used to control for cofounders and determine if helicopter transport time impacted in hospital survival even with the same duration of transit. The investigators analyzed data from 155,691 matched pairs of subjects. Helicopter transport subjects were more likely to

95 have a higher Injury Severity Score, Trauma Mortality Prediction Model predicted mortality, and rate of intensive care admission, mechanical ventilation, and transport to a level I or II trauma center. There was a statistically significant adjusted odds ratio (AOR) of in-hospital survival for transport times ranging from 6 to 30 minutes. For transport times of 5 minutes or less or 31 minutes or greater, there was no significant change in mortality. The AOR for in-hospital survival in the 6-30 minute window ranged from a peak of 1.80 in the 16-20 minute group (95% confidence interval [CI] 1.51-2.14) to a nadir of 1.46 in the 26-30 minute group (95% CI 1.11-1.93). When all emergency department deaths were excluded and when all subjects with ground transport prior to helicopter transport were excluded the statistically significant trend in survival continued over the same 6-30 minute transport window. The study investigators concluded that there is a likely survival benefit to helicopter transport over ground transport that exists over a range of transport times. As ground and helicopter subjects were only compared to those with the same transport duration, the authors conclude that there is a benefit to helicopter transport beyond speed of transit. [Robert Klemisch, MD Denver Health Medical Center, Denver, CO] Comment: This study demonstrates that there is a correlation between helicopter transport and survival that seems to be independent of speed of transport. These findings raise the question of what may cause the added benefits associated with helicopter transport. The authors speculate that it could be the expertise of helicopter-based care providers, the increased rates of transport to level I and II trauma centers, or the advanced healthcare service capabilities that most helicopter transport entities possess. Additional research is needed to delineate the nature of these advantages so that helicopter transit can be used in the most effective manner. , SYNCOPE AND MOTOR VEHICLE CRASH RISK: A DANISH NATIONWIDE STUDY. Nume´ AK, Gislason G, Christiansen CB, et al. JAMA Intern Med. 2016;176:503-10 History of syncope is a potential high-risk patient characteristic that may predispose patients to sudden incapacity while driving, thus putting themselves and others at risk of injury or death. Motor vehicle accidents are a significant cause of morbidity and mortality, and syncope behind the wheel is clearly dangerous, but first-time syncope that is not clearly cardiogenic generally does not lead to driving restrictions. This study attempted to quantify the risk of subsequent motor vehicle accidents in patients diagnosed with first-time syncope as compared to the baseline risk in the general population of Denmark. This was a retrospective populationbased cohort study from 2008 through 2012 that included all eligible Danish residents $18 years of age, a total of 4,265,301 subjects. Study authors identified 41,039 patients diagnosed with syncope in the hospital or emergency department, and followed them until one of the following outcomes–motor vehicle accident resulting in death or visit to emergency department/hospital, emigration, death, or the end

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Abstracts

of the study period. Using multivariate regression analysis to control for potential confounders, the risk of motor vehicle accident following syncope diagnosis was compared with the risk of motor vehicle accident in the general population. The syncope cohort had the following characteristics: median age 66 years, 51.0% women, 34.8% with cardiovascular disease, and a median follow-up time of 2.0 years. The general population cohort differed significantly in median age (45 years) and rate of cardiovascular disease (9.8%). Adjusting for these and a number of other patient characteristics, syncope was included in regression analysis as a time-dependent covariate to calculate the incident rate ratio (RR) of motor vehicle accident. A total of 1,791 patients with syncope (4.4%) had a subsequent motor vehicle accident, while the collective amount of accidents in the population during the study period was 226,078. The incident rate of motor vehicle accident for the syncope cohort was 20.6 per 1000 person-years (95% confidence interval [CI] 19.7-21.6), and 12.1 per 1000 person-years (95% CI 12.0-12.1), yielding an RR of 1.83 (95% CI 1.74-1.91). The authors concluded that syncope, irrespective of age or cardiovascular disease, is a significant risk factor for subsequent motor vehicle collision, and that determination of driving fitness should include history of syncope as an important comorbid condition. [James M. Tsahakis, MD Denver Health Medical Center, Denver, CO]

by the PCSS. Activity level was measured on a self-reported scale from 1 (no athletic activity beyond walking) to 7 (full game play). A multivariate Cox proportional hazard model was used to determine which variables were associated with duration of post-concussive symptoms. Among the 1,050 patients who were seen for concussion and completed questionnaires during the study period, 364 were ultimately included. Participants of this study were predominantly male (61%), spanning an age range of 8 to 27 years (mean age 15.0 years). Sixty-eight percent of patients experienced complete resolution of symptoms, with a mean duration of symptoms of 48.9 days. Female sex and initial PCSS score were independently associated with duration of symptoms. Activity level was not associated with symptom duration, and subgroup analysis showed that in adolescents (13-18 years), increased activity level post-injury was associated with shorter duration of symptoms. The study authors concluded that physical activity postconcussion may not increase duration of post-concussive symptoms. They suggest that further investigation is warranted to evaluate whether or not prolonged physical rest is the best recommendation for athletes who have suffered a concussion, particularly adolescents, who may benefit from early return to physical activity. [James M. Tsahakis, MD Denver Health Medical Center, Denver, CO]

Comment: This is a valuable population-based study, unique to a country with such excellent public health records, that encourages a worldwide re-evaluation of driving recommendations and restrictions that currently do not emphasize syncope as a potential exclusion criterion for driving. Most clinicians are familiar with seizure precautions–patients who have suffered a seizure are warned not to drive until cleared to do so by a physician or after a certain seizure-free time period. This study begs the introduction of similar precautions for patients with syncope.

Comment: This study is small in scope and is subject to considerable bias as a questionnaire-based study in which all measurement of post-concussive symptoms was subjective. However, it raises an important question as to whether the fairly universal trend of increased physical rest following concussion is the appropriate treatment for athletes, especially those in their teens.

, PHYSICAL ACTIVITY LEVEL AND SYMPTOM DURATION ARE NOT ASSOCIATED AFTER CONCUSSION. Howell DH, Mannix RC, Quinn B, et al. Am J Sports Med. 2016;44:1040-6 A commonly held maxim in the healthcare community is that athletes who suffer a concussion should undergo physical and cognitive rest following the injury in order to minimize post-concussive symptoms. Early return to unrestricted physical activity has been associated with increased severity or duration of symptoms. However, complete abstinence from physical activity may also result in poor concussion outcomes. This prospective cohort study sought to evaluate if physical activity following a concussion was associated with duration of post-concussive symptoms. Participants consisted of 364 patients seen and diagnosed in a sports concussion clinic within 21 days of injury. A questionnaire was administered to score each patient’s post-concussion symptoms scale (PCSS) and activity level at the initial clinic visit and subsequent follow-ups. Duration of symptoms was calculated from the date of injury and the patient’s reported last day of any symptoms as measured

, SUPPLY AND PERCEIVED DEMAND FOR TELEOPHTHALMOLOGY IN TRIAGE AND CONSULTATIONS IN CALIFORNIA EMERGENCY DEPARTMENTS. Wedekind L, Sainani K, Pershing S. JAMA Ophthalmol. 2016 Mar 24. doi: 10.1001/jamaophthalmol.2016.0316. [Epub ahead of print] Many emergency departments, particularly in rural settings, do not have access to emergency ophthalmology consultation, but these coverage gaps have not been characterized in published literature. Teleophthalmology consultation is a potential solution to assist emergency departments in triage of eye complaints and in caring for ophthalmologic emergencies in which an ophthalmologist is not available in person. This study sought to characterize emergency care providers’ perceptions of the need for ophthalmology services in California emergency departments, as well as the potential utility of teleophthalmology in triage and consultation. Surveys were administered to one nurse manager and one physician from each emergency department between June and September of 2014, and 187 out of the total 254 emergency departments in California were included. The survey consisted of two parts: part 1 asked a nurse manager to evaluate