Background Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not... Show moreBackground Prehospital triage protocols typically try to select patients with Injury Severity Score (ISS) above 15 for direct transportation to a Level-1 trauma center. However, ISS does not necessarily discriminate between patients who benefit from immediate care at Level-1 trauma centers. The aim of this study was to assess which patients benefit from direct transportation to Level-1 trauma centers. Methods We used the American National Trauma Data Bank (NTDB), a retrospective observational cohort. All adult patients (ISS > 3) between 2015 and 2016 were included. Patients who were self-presenting or had isolated limb injury were excluded. We used logistic regression to assess the association of direct transportation to Level-1 trauma centers with in-hospital mortality adjusted for clinically relevant confounders. We used this model to define benefit as predicted probability of mortality associated with transportation to a non-Level-1 trauma center minus predicted probability associated with transportation to a Level-1 trauma center. We used a threshold of 1% as absolute benefit. Potential interaction terms with transportation to Level-1 trauma centers were included in a penalized logistic regression model to study which patients benefit. Results We included 388,845 trauma patients from 232 Level-1 centers and 429 Level-2/3 centers. A small beneficial effect was found for direct transportation to Level-1 trauma centers (adjusted Odds Ratio: 0.96, 95% Confidence Interval: 0.92-0.99) which disappeared when comparing Level-1 and 2 versus Level-3 trauma centers. In the risk approach, predicted benefit ranged between 0 and 1%. When allowing for interactions, 7% of the patients (n = 27,753) had more than 1% absolute benefit from direct transportation to Level-1 trauma centers. These patients had higher AIS Head and Thorax scores, lower GCS and lower SBP. A quarter of the patients with ISS > 15 were predicted to benefit from transportation to Level-1 centers (n = 26,522, 22%). Conclusions Benefit of transportation to a Level-1 trauma centers is quite heterogeneous across patients and the difference between Level-1 and Level-2 trauma centers is small. In particular, patients with head injury and signs of shock may benefit from care in a Level-1 trauma center. Future prehospital triage models should incorporate more complete risk profiles. Show less
In this article, the author scrutinizes the current state of CJEU case law about VAT deduction on the purchase of goods and services by businesses, where third parties (also) benefit from these... Show moreIn this article, the author scrutinizes the current state of CJEU case law about VAT deduction on the purchase of goods and services by businesses, where third parties (also) benefit from these purchases. He also discusses case law about the VAT consequences of business funding transactions between two unrelated parties, where they have a financial interest in funding those transactions because they can lead to, for example, an increase of the turnover generated with their own taxed activities. The author comes to the conclusion that under the current provisions of the EU VAT Directive and CJEU case law, VAT deduction is not always allowed where, based on the principles of neutrality and economic reality, it should. He also offers a suggestion for adjusting the current rules in order to solve the issues that were highlighted in this article. Show less
Over the last decades, income inequality has increased globally. How do social policies affect this increasing trend? How do international trade and technological progress affect inequality? What... Show moreOver the last decades, income inequality has increased globally. How do social policies affect this increasing trend? How do international trade and technological progress affect inequality? What is the profile of income inequality in China? Based on quantitative analyses of determinants of income inequality, this study provides a number of new insights into these questions. Income inequality has increased in the last decades all over the world. Several factors seem to contribute to this trend. Very prominent amongst them is the rising primary income inequality. The dominant income inequality-reducing effect comes from the tax benefit system, which offsets two thirds of the total increase in inequality. Generally speaking, the transition of welfare states from a traditional to a social investment oriented system does not lead to lower income inequality or poverty. There is also no robust and significant relationship between international trade and technology changes on the one hand, and income inequality on the other. Determinants of inequality in China are different from those in developed countries. In contrast to the tax benefit system in rich countries, the fiscal system in China does not bring a lower level of income inequality. Another explanation is the household registration system. Show less
