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Aluisio AR, Waheed S, Cameron P, Hess J, Jacob ST, Kissoon N, Levine AC, Mian A, Ramlakhan S, Sawe HR, Razzak J. Clinical emergency care research in low-income and middle-income countries: opportunities and challenges. BMJ Glob Health 2019; 4:e001289. [PMID: 31406600 PMCID: PMC6666826 DOI: 10.1136/bmjgh-2018-001289] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/05/2019] [Accepted: 01/12/2019] [Indexed: 12/29/2022] Open
Abstract
Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth.
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Affiliation(s)
- Adam R Aluisio
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Shahan Waheed
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jermey Hess
- Department of Emergency Medicine, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Shevin T Jacob
- Division of Allergy and Infectious Diseases, Universityof Washington, Seattlel, WA, United States
| | - Niranjan Kissoon
- Departmentof Pediatrics and Emergency Medicine, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Asad Mian
- Department of Emergency Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Shammi Ramlakhan
- Emergency Department, Sheffield Children's Hospital, Sheffield, UK.,Faculty of Medical Sciences, University of the West Indies, Kingston, Jamaica
| | - Hendry R Sawe
- Emergency Medicine Department, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Junaid Razzak
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Carter PM, Cook LJ, Macy ML, Zonfrillo MR, Stanley RM, Chamberlain JM, Fein JA, Alpern ER, Cunningham RM. Individual and Neighborhood Characteristics of Children Seeking Emergency Department Care for Firearm Injuries Within the PECARN Network. Acad Emerg Med 2017; 24:803-813. [PMID: 28423460 PMCID: PMC5515362 DOI: 10.1111/acem.13200] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/20/2017] [Accepted: 03/23/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The objective was to describe the characteristics of children seeking emergency care for firearm injuries within the PECARN network and assess the influence of both individual and neighborhood factors on firearm-related injury risk. METHODS This was a retrospective, multicenter cross-sectional analysis of children (<19 years old) presenting to 16 pediatric EDs (2004-2008). ICD-9-CM E-codes were used to identify and categorize firearm injuries by mechanism/intent. Neighborhood variables were derived from home address data. Multivariable analysis examined the influence of individual and neighborhood factors on firearm-related injuries compared to nonfirearm ED visits. Injury recidivism was assessed. RESULTS A total of 1,758 pediatric ED visits for firearm-related injuries were analyzed. Assault (51.4%, n = 904) and unintentional injury (33.2%, n = 584) were the most common injury mechanisms. Among children with firearm injuries, 68.3% were older adolescents (15-19 years old), 82.3% were male, 68.2% were African American, and 76.3% received public insurance/were uninsured. Extremity injuries were most common (75.9%), with 20% sustaining injuries to multiple body regions, 48.1% requiring admission and 1% ED mortality. Multivariable analysis identified firearm injury risk factors, including adolescent age (p < 0.001), male sex (p < 0.001), non-Caucasian race/ethnicity (p < 0.001), public payer/uninsured status (p < 0.001), and higher levels of neighborhood disadvantage (p < 0.001). Among children with firearm injuries, 12-month ED recidivism for any reason was 22.4%, with < 1% returning for another firearm injury. CONCLUSION Among children receiving ED treatment within the PECARN network, there are distinct demographic and neighborhood factors associated with firearm injuries. Among younger children (<10 years old), unintentional injuries predominate, while assault-type injuries were most common among older adolescents. Overall, among this PECARN patient population, male adolescents living in neighborhoods characterized by high levels of concentrated disadvantage had an elevated risk for firearm injury. Public health efforts should focus on developing and implementing initiatives addressing risk factors at both the individual and the community level, including ED-based interventions to reduce the risk for firearm injuries among high-risk pediatric populations.
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Affiliation(s)
- Patrick M Carter
- University of Michigan, Injury Center, Ann Arbor, MI
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
- Youth Violence Prevention Center, School of Public Health, Ann Arbor, MI
| | - Lawrence J Cook
- Department of Pediatrics, Division of Critical Care, University of Utah, School of Medicine, Salt Lake City, UT
| | - Michelle L Macy
- University of Michigan, Injury Center, Ann Arbor, MI
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, University of Michigan, School of Medicine, Ann Arbor, MI
- University of Michigan, C.S. Mott Children's Hospital, Child Health Evaluation and Research (CHEAR) Unit, Ann Arbor, MI
| | - Mark R Zonfrillo
- Department of Emergency Medicine and Injury Prevention Center, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
| | - Rachel M Stanley
- Department of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - James M Chamberlain
- Department of Emergency Medicine and Trauma Services, Children's National Health System, Washington, DC
| | - Joel A Fein
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth R Alpern
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Rebecca M Cunningham
- University of Michigan, Injury Center, Ann Arbor, MI
- Department of Emergency Medicine, School of Medicine, University of Michigan, Ann Arbor, MI
- Youth Violence Prevention Center, School of Public Health, Ann Arbor, MI
- Department of Health Behavior & Health Education, University of Michigan, School of Public Health, Ann Arbor, MI
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Wesson HKH, Bachani AM, Mtambeka P, Schulman D, Mavengere C, Ward Millar AJ, Hyder AA, van As AB. Changing state of pediatric injuries in South Africa: An analysis of surveillance data from a Pediatric Emergency Department from 2007 to 2011. Surgery 2017; 162:S4-S11. [PMID: 28483163 DOI: 10.1016/j.surg.2017.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/14/2017] [Accepted: 03/15/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pediatric injuries are associated with significant morbidity and mortality, especially in low- and middle-income countries. Data to characterize the cause and risk factors associated with childhood injuries in low- and middle-income countries are very scarce. The aim of this study is to describe the cause of pediatric injuries and their possible changes between 2007 and 2011 using hospital-based data in Cape Town, South Africa. METHODS Data from injured children <13 years of age who presented to the Red Cross War Memorial Children's Hospital's emergency department in 2007 and 2011 were captured in Childsafe South Africa's trauma surveillance system. Poisson regression was used to assess changes in rates of injury between 2007 and 2011 in terms of demographics, geographic location of injury, type of injury mechanism, injury severity, and anatomic region of the sustained injury. RESULTS In total, 14,915 injured children with 15,414 injuries presented to Red Cross War Memorial Children's Hospital in 2007 and 2011. The mean age was 5.01 ± 3.5 years and 60.3% were male. Common mechanisms of injury included falls (n = 6,036; 40%), road traffic injuries (n = 1,939; 13%), burns (n = 1,885; 12.6%), and assault (n = 640; 4.3%). Comparing 2011 to 2007, the incidence of road traffic injuries has decreased by 7% (P < .05) while burn injuries increased 11% (P < .05). Seventy-three percent (73%) of injuries that presented to Red Cross War Memorial Children's Hospital occurred in the Cape Flats area of Cape Town, where many informal settlements exist. CONCLUSION These epidemiologic findings suggest that while road traffic injuries decreased and burn injuries increased at Red Cross War Memorial Children's Hospital, there is a need for data that are population-based and not hospital based. If we could describe injuries accurately within the pediatric population of a city such as Cape Town, we could in turn use this data to strengthen the need for targeted interventions to address risk factors for pediatric injuries. Despite this, hospital-based data remain a powerful tool to study injuries in low and middle-income countries.
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Affiliation(s)
| | - Abdulgafoor M Bachani
- International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Patricia Mtambeka
- Childsafe South Africa, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Dorothy Schulman
- Childsafe South Africa, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Chiedza Mavengere
- Childsafe South Africa, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Alastair John Ward Millar
- Department of Pediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Adnan A Hyder
- International Injury Research Unit, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Arjan Bastiaan van As
- Department of Pediatric Surgery, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Ranney ML, Fletcher J, Alter H, Barsotti C, Bebarta VS, Betz ME, Carter PM, Cerdá M, Cunningham RM, Crane P, Fahimi J, Miller MJ, Rowhani-Rahbar A, Vogel JA, Wintemute GJ, Shah MN, Waseem M. A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research. Ann Emerg Med 2017; 69:227-240. [PMID: 27998625 PMCID: PMC5272847 DOI: 10.1016/j.annemergmed.2016.08.454] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/17/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda. METHODS National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated. RESULTS Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings. CONCLUSION The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.
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Affiliation(s)
- Megan L. Ranney
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI
| | - Jonathan Fletcher
- Department of Emergency Medicine, Alpert Medical School, Brown University, Providence, RI
| | - Harrison Alter
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | | | - Vikhyat S. Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Marian E. Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Patrick M. Carter
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI
| | - Magdalena Cerdá
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Rebecca M. Cunningham
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI; University of Michigan Injury Center, University of Michigan, Ann Arbor, MI
| | - Peter Crane
- Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Jahan Fahimi
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Matthew J. Miller
- Department of Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA
| | - Ali Rowhani-Rahbar
- Department of Epidemiology and Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA
| | - Jody A. Vogel
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health Medical Center, University of Colorado School of Medicine, Aurora, CO
| | - Garen J. Wintemute
- Department of Emergency Medicine, University of California, Davis, Sacramento, CA
| | - Manish N. Shah
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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King AJ, Farst KJ, Jaeger MW, Onukwube JI, Robbins JM. Maltreatment-Related Emergency Department Visits Among Children 0 to 3 Years Old in the United States. CHILD MALTREATMENT 2015; 20:151-161. [PMID: 25631298 PMCID: PMC9254131 DOI: 10.1177/1077559514567176] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The emergency department (ED) is a vital entry point in the health care system for children who experience maltreatment. This study fills a gap in the maltreatment literature by presenting systematic, national estimates of maltreatment-related ED visits in the United States by children ≤3 years old, from 2006 to 2011, using the Nationwide Emergency Department Sample (NEDS). Children who experienced and likely experienced maltreatment were identified via International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. Maltreatment was classified as physical or sexual abuse, neglect, or poly-victimization. The clinical and demographic profiles of children who experienced maltreatment were described. Approximately 10,095 children who experienced maltreatment (0.1% of total ED visits) and 129,807 children who likely experienced maltreatment (1.2% of total ED visits) were documented each year. Maltreatment was associated with significantly greater risk of injury, hospitalization, and death in the ED setting. Physical abuse was the most common explicit maltreatment diagnosis (33 ED visits per 100,000 children ≤3 years old) and neglect was the most common likely maltreatment diagnosis (436 ED visits per 100,000 children ≤3 years old). This study established the NEDS as a valuable complement to existing surveillance efforts of child maltreatment from a public health perspective.
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Affiliation(s)
- Andrew J King
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Karen J Farst
- Center for Children at Risk, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Matthew W Jaeger
- Pediatric Emergency Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jennifer I Onukwube
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James M Robbins
- Center for Applied Research and Evaluation, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Salamati P, Rahimi-Movaghar A, Motevalian SA, Amin-Esmaeili M, Sharifi V, Hajebi A, Rad Goodarzi R, Hefazi M, Naji Z, Saadat S, Rahimi-Movaghar V. Incidence of self-reported interpersonal violence related physical injury in iran. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e15986. [PMID: 26019893 PMCID: PMC4441782 DOI: 10.5812/ircmj.15986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 08/28/2014] [Accepted: 12/22/2014] [Indexed: 11/25/2022]
Abstract
Background: Violence is the cause of death for 1.5 million people in a year. Objectives: Our study aimed to estimate the incidence rate of self-reported interpersonal violence related physical injury (VRPI) and its associated factors in Iran. Patients and Methods: The sample included people ranged from 15 to 64 years old who were residing in Iran. A total of 1525 clusters were selected from the whole country. Six families were selected from each cluster via a systematic random sampling method. Then, the residential units were identified and the interviewers contacted the inhabitants. In the next step, one of the family members was selected by using Kish grid method. The instrument was a researcher-made questionnaire and consisted of two sections; demographics and project related data. Face validity and content validity of our questionnaire were investigated based on expert opinions and the reliability was confirmed by a pilot study, as well. The inclusion criteria were considered for choosing the interviewers. An interviewer was assigned for each 42 participants (7 clusters). An educational seminar was held for the administrative managers (54 persons) and interviewers (230 persons) for a week. The field work was distributed among all 46 Medical Sciences universities in Iran. In each university, administrative issues were related to an executive director. Mann-Whitney U test and odds ratio were used to analyze the data with 95% confidence interval. α value was considered less than 5%. Results: The frequency of VRPI among 7886 participants was 24 during the last three months. The incidence rate of interpersonal VRPI was estimated at 3.04 per 1000 population (95% CI: 2.66-3.42) during a three-month interval in Iran. The incidence was 4.72 per 1000 population (95% CI: 4.01-5.43) for males and 1.78 per 1000 population (95% CI: 1.39-2.17) for females during a three-month interval. The mean (SD) of age of the participants with and without a history of VRPI were 26.5 (7.21) and 33.05 (12.05) years, respectively (P = 0.008). Considering the participants’ gender, 66.7% were males (OR = 2.66, 95% CI: 1.14-6.23). Khuzestan Province had the most VRPIs (25% of all VRPIs). Streets and roads were the places with the highest frequency of injury (50%). The most frequent injured organ was the upper limb (54.17%). The most prevalent type of injury was a superficial wound (50%). Finally, the most common place of treatment was home (45.83%). Conclusions: We determined the incidence rate of self-reported interpersonal VRPI for the first time in Iran based on a national survey. The injuries were more common among young men. We suggest consecutive national surveys with different data gathering methods and more sample sizes.
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Affiliation(s)
- Payman Salamati
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Seyed Abbas Motevalian
- School of Public Health, Iranian National Center for Addiction Studies (INCAS), Iran University of Medical Sciences, Tehran, IR Iran
| | - Masoumeh Amin-Esmaeili
- Iranian Research Center for HIV/AIDS (IRCHA), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Vandad Sharifi
- Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Ahmad Hajebi
- Tehran Psychiatric Institute, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Reza Rad Goodarzi
- Iranian Research Center for HIV/AIDS (IRCHA), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mitra Hefazi
- Iranian Research Center for HIV/AIDS (IRCHA), Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Zohrehsadat Naji
- Department of Theology, Quran and Hadith University, Hazrat-e Abdul-Azim Holy Shrine, Rey City, Tehran, IR Iran
| | - Soheil Saadat
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding Author: Vafa Rahimi-Movaghar, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2166757001, E-mail:
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Snider CE, Lee JS. Emergency department dispositions among 4100 youth injured by violence: a population-based study. CAN J EMERG MED 2015; 9:164-9. [PMID: 17488575 DOI: 10.1017/s1481803500014998] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT
Objective:
Concern about youth violence in Canada is growing. Because victims of violence are more likely to become future violent perpetrators, preventative interventions are often based out of inpatient units; however, the question of how often youth who have been injured due to violence are discharged from emergency departments (EDs), or whether there are opportunities for emergency healthcare workers to deliver violence prevention programs, is not known. The primary objectives of this study were to describe the frequency and patterns of violent injuries among youth, to determine how many injured youth are discharged directly from EDs and to estimate the proportion of injured youth who may benefit from ED-based intervention programs.
Methods:
We conducted an observational study using a population-based database that records information on all ED visits in Ontario. We analyzed age, sex, cause of injury and disposition for all patients aged 12–19 years who presented to Toronto EDs with violent injuries during a 2-year period (April 2002 to March 2004).
Results:
A total of 4100 patients aged 12–19 years visited Toronto EDs with violent injuries during the study period. Assault due to bodily force (in contrast to sharp objects, guns or other) was the most common injury mechanism, accounting for 48.7% of cases (95% confidence interval [CI] 47.1%–50.2%). The majority of patients (89.3%; 95% CI 88.3%–90.2%) were discharged directly from EDs, including 44% of gun-related injuries.
Conclusion:
In Toronto, a large proportion (89.3%) of youth injured in violent incidents are discharged directly from EDs. There are opportunities to develop ED-based youth violence prevention initiatives.
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Affiliation(s)
- Carolyn E Snider
- Division of Emergency Medicine, University of Toronto, Toronto, Ontario, Canada.
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Newgard CD, Kuppermann N, Holmes JF, Haukoos JS, Wetzel B, Hsia RY, Wang NE, Bulger EM, Staudenmayer K, Mann NC, Barton ED, Wintemute G. Gunshot injuries in children served by emergency services. Pediatrics 2013; 132:862-70. [PMID: 24127481 PMCID: PMC3813400 DOI: 10.1542/peds.2013-1350] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms. METHODS This was a population-based, retrospective cohort study (January 1, 2006-December 31, 2008) including all injured children age ≤ 19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥ 16, major surgery, blood transfusion, mortality, and average per-patient acute care costs. RESULTS A total of 49,983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15-19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100,000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6-28.4), major surgery (32%, 95% CI 26.1-38.5), in-hospital mortality (8.0%, 95% CI 4.7-11.4), and costs ($28,510 per patient, 95% CI 22,193-34,827). CONCLUSIONS Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - James F. Holmes
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado;,Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado
| | - Brian Wetzel
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California
| | | | - Eileen M. Bulger
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - N. Clay Mann
- Intermountain Injury Control Research Center, University of Utah, Salt Lake City, Utah; and
| | - Erik D. Barton
- Division of Emergency Medicine, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Garen Wintemute
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
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Monitoring the multi-faceted problem of youth violence: the Asian/Pacific Islander Youth Violence Prevention Center's surveillance system. J Community Health 2013; 37:1015-25. [PMID: 22231577 DOI: 10.1007/s10900-011-9525-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Youth violence (YV) is a complex public health issue that spans geographic, ethnic, and socioeconomic lines. The Asian/Pacific Islander Youth Violence Prevention Center conducts qualitative and quantitative research on YV in Hawai'i. A critical element in YV prevention involves measuring YV and its risk-protective factors to determine the scope of the problem and to monitor changes across time. Under the Asian/Pacific Islander Youth Violence Prevention Center's (APIYVPC's) surveillance umbrella, a variety of methodologies are utilized. The major forms of active surveillance are a School-Wide Survey for youth, and a Safe Community Household Survey for adults. A variety of secondary data sources are accessed, such as the Centers for Disease Control and Prevention (Youth Risk Behavior Surveillance System), the Hawai'i State Department of the Attorney General, the Hawai'i State Department of Education, and the Hawai'i State Department of Health. State data are especially important for the Center, because most of these sources disaggregate ethnicity data for Asian Americans/Pacific Islanders. This paper details the surveillance methodologies utilized by the APIYVPC to monitor YV in one specific community and in Hawai'i, in comparison to the rest of the State and nation. Empirical results demonstrate the utility of each methodology and how they complement one another. Individually, each data source lends valuable information to the field of YV prevention; however, collectively, the APIYVPC's surveillance methods help to paint a more complete picture regarding violence rates and the relationship between YV and its risk-protective factors, particularly for minority communities.
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Abstract
BACKGROUND Based on our previous study, pediatric intentional trauma injuries with Injury Severity Scores (ISS) ≥ 12 were more commonly observed in the urban than the rural setting (15.2% vs. 5.5%) in Alberta from 1996 to 2006. We wish to understand differences between urban and rural pediatric intentional trauma to plan for prevention and supportive strategies. METHODS Data were extracted from the Alberta Trauma Registry on pediatric patients (0-17 years) with ISS ≥ 12, treated from 1996 to 2010 at the Stollery Children's Hospital. Statistical analysis was made comparing urban versus rural groups using t test and χ2 with p < 0.05 considered significant. RESULTS There were 170 pediatric patients who suffered intentional injury (urban = 58.3%; rural = 41.8%; not significant), with a majority of males (72.4%). Two groups were predominant: the very young (<1 year) at 17.1% of all injuries and the teens (≥ 15 years) at 54.1%. The cause of intent injury was child abuse (31.2%), assault with blunt object (24.6%), assault with a sharp object (22.9%), and suicide (18.2%). The mean ISS was 22.9 ± 7.8 standard deviation. Tragically, 29 patients (17.1%) died. There were no differences between urban and rural pediatric trauma in terms of age, gender, cause of injury, ISS, survival, length of stay, pediatric intensive care unit length of stay, number of operations needed, or alcohol. CONCLUSION An important pattern of intentional injuries can be seen where preventative efforts can be strengthened regardless of urban or rural area: the very young as shaken baby cases and the teens, who unfortunately, accounted for the majority of suicidal attempts.
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Ranney ML, Whiteside L, Walton MA, Chermack ST, Zimmerman MA, Cunningham RM. Sex differences in characteristics of adolescents presenting to the emergency department with acute assault-related injury. Acad Emerg Med 2011; 18:1027-35. [PMID: 21996067 DOI: 10.1111/j.1553-2712.2011.01165.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Adolescents with a history of peer assault are known to report high rates of other risky behaviors. The characteristics of adolescents seeking care in the ED for acute assault-related injury are less well established. This knowledge deficit is particularly noticeable for adolescent female victims of peer assault. This study's objectives were: 1) to characterize the demographics and risk behaviors of youths presenting to the emergency department (ED) with acute assault-related injury and 2) to compare assaulted youths' demographic characteristics, past experiences with violence, and other risk behaviors by sex. METHODS A systematic sample of adolescents (ages 14 to 18 years) presenting to an urban ED with acute assault-related injury (excluding dating violence, sexual assault, and child abuse) was recruited. Consenting participants self-administered a computerized survey about demographics, history of peer and dating aggression, and theoretical correlates of violence (e.g., alcohol and other drug use, depressive symptoms, weapon carriage). Multivariate logistic regression was performed to identify factors that were differentially associated with presentation to the ED for acute assault-related injury for females versus males. RESULTS Of 3,338 adolescents completing a screening survey during the 36-month study period, 197 had presented to the ED with acute assault-related injuries; seven of these were excluded from this study due to being victims of dating violence. Most (n = 179, 94.2%) of these 190 acutely assaulted participants were discharged home. The majority reported a history of past-year peer aggression (n = 160, 84.2%) and past-year violent injury (n = 106, 55.8%). Similar rates of past-year peer aggression, past-year violent injury, alcohol use, and weapon carriage were observed for adolescent males and females presenting with acute assault-related injury. Males and females also reported similar age, race, socioeconomic status, and education levels. Compared to males, females were less likely to report living with a parent (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.08 to 0.84) and were more likely to report depressive symptoms (OR = 2.59, 95% CI = 1.23 to 5.48) and past-year dating aggression (OR = 2.23, 95% CI = 1.04 to 4.82). CONCLUSIONS Male and female adolescents with acute assault-related injuries were very similar. Both reported extremely high rates of past year peer violence, assault-related injury, and substance use. The greater prevalence of some risk factors among adolescent females, such as depressive symptoms, dating aggression, and independent living status, should be further investigated.
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Affiliation(s)
- Megan L Ranney
- Injury Prevention Center, Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA.
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Broderick KB, Ranney ML, Vaca FE, D'Onofrio G, Rothman RE, Rhodes KV, Becker B, Haukoos JS. Study designs and evaluation models for emergency department public health research. Acad Emerg Med 2009; 16:1124-31. [PMID: 20053232 DOI: 10.1111/j.1553-2712.2009.00557.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract Public health research requires sound design and thoughtful consideration of potential biases that may influence the validity of results. It also requires careful implementation of protocols and procedures that are likely to translate from the research environment to actual clinical practice. This article is the product of a breakout session from the 2009 Academic Emergency Medicine consensus conference entitled "Public Health in the ED: Screening, Surveillance, and Intervention" and serves to describe in detail aspects of performing emergency department (ED)-based public health research, while serving as a resource for current and future researchers. In doing so, the authors describe methodologic features of study design, participant selection and retention, and measurements and analyses pertinent to public health research. In addition, a number of recommendations related to research methods and future investigations related to public health work in the ED are provided. Public health investigators are poised to make substantial contributions to this important area of research, but this will only be accomplished by employing sound research methodology in the context of rigorous program evaluation.
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Affiliation(s)
- Kerry B Broderick
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.
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Walton MA, Cunningham RM, Goldstein AL, Chermack ST, Zimmerman M, Bingham CR, Shope JT, Stanley R, Blow FC. Rates and correlates of violent behaviors among adolescents treated in an urban emergency department. J Adolesc Health 2009; 45:77-83. [PMID: 19541253 PMCID: PMC3000121 DOI: 10.1016/j.jadohealth.2008.12.005] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 11/12/2008] [Accepted: 12/04/2008] [Indexed: 11/30/2022]
Abstract
PURPOSE Violence is a leading cause of death for adolescents in inner-city settings. This article describes violent behaviors in relation to other risk behaviors (e.g., substance use) among adolescents screened in an urban emergency department (ED). METHODS Patients aged 14-18 years were approached to self-administer a computerized survey assessing violent behaviors (i.e., physical aggression), substance use (cigarettes, alcohol, marijuana), and weapon carriage. RESULTS A total of 1128 adolescents (83.8% participation rate; 45.9% male; 58.0% African-American) were surveyed. In the past year, 75.3% of adolescents reported peer violence, 27.6% reported dating violence, and 23.5% reported carrying a weapon. In the past year, 28.0% drank alcohol, 14.4% binge drank, 5.7% reported alcohol-related fighting, and 36.9% smoked marijuana. Logistic regression analyses predicting violent behaviors were significant. Teens reporting peer violence were more likely to be younger, African-American, on public assistance, carry a weapon, binge drink, and smoke marijuana. Teens reporting dating violence were more likely to be female, African-American, carry a weapon, binge drink, screen positive for alcohol problems, and smoke marijuana. Teens reporting alcohol-related fighting were more likely to carry a weapon, binge drink, screen positive for alcohol problems, and smoke marijuana. CONCLUSIONS Adolescents presenting to an urban ED have elevated rates of violent behaviors. Substance use (i.e., binge drinking and smoking marijuana) is an important risk factor for violent behaviors among urban adolescents. Universal screening and intervention protocols to address multiple risk behaviors, including violent behaviors and substance use, may be useful to prevent injury among adolescents presenting to the urban ED.
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Affiliation(s)
| | - Rebecca M. Cunningham
- Department of Emergency Medicine and Hurley Medical Center, University of Michigan, School of Public Health, University of Michigan
| | | | | | | | | | - Jean T. Shope
- Transportation Research Institute, University of Michigan, School of Public Health, University of Michigan
| | - Rachel Stanley
- Department of Emergency Medicine and Hurley Medical Center, University of Michigan
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Abstract
Youth violence continues to be a serious threat to the health of children and adolescents in the United States. It is crucial that pediatricians clearly define their role and develop the appropriate skills to address this threat effectively. From a clinical perspective, pediatricians should become familiar with Connected Kids: Safe, Strong, Secure, the American Academy of Pediatrics' primary care violence prevention protocol. Using this material, practices can incorporate preventive education, screening for risk, and linkages to community-based counseling and treatment resources. As advocates, pediatricians may bring newly developed information regarding key risk factors such as exposure to firearms, teen dating violence, and bullying to the attention of local and national policy makers. This policy statement refines the developing role of pediatricians in youth violence prevention and emphasizes the importance of this issue in the strategic agenda of the American Academy of Pediatrics.
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Sege RD, Hoffman JS. Training health professionals in youth violence prevention: overview of extant efforts. Am J Prev Med 2005; 29:175-81. [PMID: 16376713 DOI: 10.1016/j.amepre.2005.08.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2005] [Revised: 08/23/2005] [Accepted: 08/25/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Robert D Sege
- Department of Pediatrics, Tufts University School of Medicine, Tufts-New England Medical Center, Boston, Massachusetts 02111, USA.
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Abstract
OBJECTIVE Nonfatal fight-related injuries among youths result in lost capacity and high costs of medical care and rehabilitation and constitute a major public health problem. This study identifies factors that predict the occurrence of a fight-related injury that requires medical attention among boys and girls. METHODS We analyzed data from 14 787 adolescents who completing 2 interviews, approximately 1 year apart, in the National Longitudinal Study of Adolescent Health, a nationally representative, school-based sample of youths. We identified time 1 factors at the community, family, and individual levels that predicted any self-reported fight-related injury that required medical treatment at time 2. RESULTS Factors that predict future injury among both boys and girls in multivariate models were violence-related factors: witnessing or being a victim of violence (odds ratio [OR]: 3.69; 95% confidence interval [CI]: 1.81-7.49 for boys; OR: 5.13; 95% CI: 1.25-21.09 for girls), history of a violence-related injury (OR: 2.30; 95% CI: 1.60-3.29 for boys; OR: 3.18; 95% CI: 1.87-5.41 for girls), and physical fighting (OR: 2.02; 95% CI: 1.44-2.84 for boys; OR: 5.15; 95% CI: 3.18-8.34 for girls). Among boys, illicit drug use was also an independent predictor of future injury (OR: 1.72; 95% CI: 1.24-2.37), whereas excellent perceived general health (OR: 0.48; 95% CI: 0.25-0.93) and a high grade point average (OR: 0.52; 95% CI: 0.29-0.95) were significant protective factors against fight-related injury. Girls who reported a high level of depressive symptoms were much more likely to report fight-related injury than nondepressed girls (OR: 8.98; 95% CI: 2.43-33.25). CONCLUSIONS Factors related to violence, substance use, school achievement, and physical and mental health predicted a future fight-related injury that required medical treatment. The results could assist health and social service providers, educators, and others in identifying youths who are at high risk for fight-related injury and may benefit from appropriate intervention.
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Affiliation(s)
- Iris Wagman Borowsky
- Division of General Pediatrics and Adolescent Health, University of Minnesota, Minneapolis, Minnesota 55455-2002, USA.
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Wright JL, Edgerton EA. Public health, emergency medicine, and the community interface. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2003. [DOI: 10.1016/s1522-8401(03)00026-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Keshavarz R, Kawashima R, Low C. Child abuse and neglect presentations to a pediatric emergency department. J Emerg Med 2002; 23:341-5. [PMID: 12480011 DOI: 10.1016/s0736-4679(02)00575-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This study describes the epidemiology of reported abuse (physical, sexual, and neglect) in a teaching, metropolitan Pediatric Emergency Department (PED) with approximately 30,000 annual visits. A retrospective chart review was conducted of all cases from the PED that were referred to the Department of Social Work and reported to the Administration for Children's Services (ACS), the New York children's protective services, from May 1996 through December 1998. Demographic information about the victims as well as past medical history, number of previous PED visits, information about the perpetrator and the nature of the injuries were obtained. We identified 106 cases over this period of time that were reported for child abuse or neglect from the PED. Fifty-five percent of cases were reported for suspected physical abuse, 15% for sexual abuse, and 30% for neglect. The suspected perpetrator was the mother in 41% of cases and the father in 21% of cases. Bruises were the most frequent injury reported, seen in 25% of cases. The mean age of the patients was 6.4 years old. They averaged 4.6 previous PED visits. The majority of patients lived near the hospital. Sixty-nine percent of the patients presented for care between the hours of 5 PM and 9 AM. Most of the patients claimed their primary physician was located in a clinic near their home (44%). Only 12.7% were unsure of their primary physician. Significantly more victims (89%) had Medicaid or no insurance compared with other PED patients (71%). Victims did not live in zip codes with lower incomes compared with other PED patients. Upon complete investigation by ACS, 49 cases (46%) were deemed 'indicated,' 21 cases (20%) 'unfounded,' and for the remaining 36 cases (34%) follow-up information could not be determined. The incidence of reported abuse and neglect was lower than previous studies have shown. The majority of reported cases (especially those of sexual abuse) did not have any physical findings at the time of presentation, stressing the need of a careful search for both abuse and neglect.
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Affiliation(s)
- Reza Keshavarz
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York 10029, USA
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