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Calame DJ, Riaz M. Pediatric craniocerebral firearm injuries: literature review, best practices in medical and surgical management, and case report. Childs Nerv Syst 2023; 39:2195-2199. [PMID: 37100970 DOI: 10.1007/s00381-023-05968-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/19/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION Civilian craniocerebral firearm injuries are extremely lethal. Management includes aggressive resuscitation, early surgical intervention when indicated, and management of intracranial pressure. Patient neurological status and imaging features should be used to guide management and the degree of intervention. Pediatric craniocerebral firearm injuries have a higher survival rate, but are much rarer, especially in children under 15 years old. This paucity of data underscores the importance of reviewing pediatric craniocerebral firearm injuries to determine best practices in surgical and medical management. CASE PRESENTATION A 2-year-old female was admitted after suffering a gunshot wound to the left frontal lobe. Upon initial evaluation, the patient displayed agonal breathing and fixed pupils with a GCS score of 3. CT imaging showed a retained ballistic projectile in the right temporal-parietal region with bifrontal hemorrhages, subarachnoid blood, and a 5-mm midline shift. The injury was deemed nonsurvivable and non-operable; thus, treatment was primarily supportive. Upon removal of the endotracheal tube, the patient began breathing spontaneously and improved clinically to a GCS score of 10-12. On hospital day 8, she underwent cranial reconstruction with neurosurgery. Her neurological status continued to improve, and she was able to communicate and follow commands but retained notable left-sided hemiplegia with some left-sided movement. On hospital day 15, she was deemed safe for discharge to acute rehabilitation.
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Affiliation(s)
- D J Calame
- Medical Scientist Training Program, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Department of Physiology and Biophysics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - M Riaz
- Department of Neurosurgery, Denver Health Medical Center, Denver, CO, USA
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Amato S, Culbreath K, Dunne E, Sarathy A, Siroonian O, Sartorelli K, Roy N, Malhotra A. Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis. J Pediatr Surg 2023; 58:99-105. [PMID: 36328820 DOI: 10.1016/j.jpedsurg.2022.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US). METHODS A retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality. RESULTS 126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70-27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity. CONCLUSIONS Risk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India. TYPE OF STUDY Retrospective Prognosis Study LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Stas Amato
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA.
| | - Katherine Culbreath
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA; Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Emma Dunne
- University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Ashwini Sarathy
- University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Olivia Siroonian
- Department of Pharmacology, University of Vermont, Larner College of Medicine, 89 Beaumont Ave, Burlington, VT 05401, USA
| | - Kennith Sartorelli
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA
| | - Nobhojit Roy
- The George Institute for Global Health, 308, Third Floor, Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi 110025, India; WHO Collaborating Centre for Research in Surgical Care Delivery, Anushakti Nagar, Mumbai, MH 400094, India
| | - Ajai Malhotra
- Department of Surgery, University of Vermont Medical Center, 111 Colchester Ave, Burlington, VT 05401, USA
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Dipnall JF, Rivara FP, Lyons RA, Ameratunga S, Brussoni M, Lecky FE, Bradley C, Beck B, Lyons J, Schneeberg A, Harrison JE, Gabbe BJ. Predictors of health-related quality of life following injury in childhood and adolescence: a pooled analysis. Inj Prev 2021; 28:301-310. [PMID: 34937765 DOI: 10.1136/injuryprev-2021-044309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 11/12/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Injury is a leading contributor to the global disease burden in children and places children at risk for adverse and lasting impacts on their health-related quality of life (HRQoL) and development. This study aimed to identify key predictors of HRQoL following injury in childhood and adolescence. METHODS Data from 2259 injury survivors (<18 years when injured) were pooled from four longitudinal cohort studies (Australia, Canada, UK, USA) from the paediatric Validating Injury Burden Estimates Study (VIBES-Junior). Outcomes were the Paediatric Quality of Life Inventory (PedsQL) total, physical, psychosocial functioning scores at 1, 3-4, 6, 12, 24 months postinjury. RESULTS Mean PedsQL total score increased with higher socioeconomic status and decreased with increasing age. It was lower for transport-related incidents, ≥1 comorbidities, intentional injuries, spinal cord injury, vertebral column fracture, moderate/severe traumatic brain injury and fracture of patella/tibia/fibula/ankle. Mean PedsQL physical score was lower for females, fracture of femur, fracture of pelvis and burns. Mean PedsQL psychosocial score was lower for asphyxiation/non-fatal submersion and muscle/tendon/dislocation injuries. CONCLUSIONS Postinjury HRQoL was associated with survivors' socioeconomic status, intent, mechanism of injury and comorbidity status. Patterns of physical and psychosocial functioning postinjury differed according to sex and nature of injury sustained. The findings improve understanding of the long-term individual and societal impacts of injury in the early part of life and guide the prioritisation of prevention efforts, inform health and social service planning to help reduce injury burden, and help guide future Global Burden of Disease estimates.
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Affiliation(s)
- Joanna F Dipnall
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia .,Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria, Australia
| | - Frederick P Rivara
- Departments of Pediatrics and Epidemiology, and the Harborview Injury Prevention and Research Center, University of Washington, Seattle, Washington, USA
| | - Ronan A Lyons
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Health Data Research UK, Swansea University, Swansea, UK.,National Centre for Population Health and Wellbeing Research, Swansea University, Swansea, UK
| | - Shanthi Ameratunga
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Population Health, University of Auckland, Auckland, New Zealand.,Kidz First Hospital and Population Health Directorate, Counties Manukau District Health Board, Auckland, New Zealand
| | - Mariana Brussoni
- Department of Pediatrics, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,British Columbia Injury Research and Prevention Unit, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Fiona E Lecky
- Centre for Urgent and Emergency Care Research, School of Health and Related Research, University of Sheffield, Sheffield, UK.,Emergency Department, Salford Royal Hospital, Salford, UK
| | - Clare Bradley
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jane Lyons
- Health Data Research UK, Swansea University, Swansea, UK
| | - Amy Schneeberg
- British Columbia Injury Research and Prevention Unit, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - James E Harrison
- Flinders Institute for Health and Medical Research, Flinders University, Adelaide, South Australia, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Health Data Research UK, Swansea University, Swansea, UK
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Lewis SL, Liebe H, Jeffery C, Sebastian R, Stewart KE, Sarwar Z, Gamino L, Johnson JJ. Traumatic Pediatric Fatalities: Are They Preventable? J Surg Res 2021; 269:158-164. [PMID: 34563842 DOI: 10.1016/j.jss.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Trauma related injury remains the leading cause of mortality in pediatric patients, many of which are preventable. The goal of our study was to identify the mechanism of injury (MOI) in pediatric trauma-related fatalities and determine if these injuries were preventable to direct future injury prevention efforts within trauma programs. METHODS After IRB approval, a retrospective, single-institution review of pediatric (age ≤18) trauma fatalities from 2010 to 2019 was performed. MOI, use of protective devices, demographics, and whether the injury was preventable were collected. Patients were divided into five age cohorts, and frequencies and proportions were used to summarize data. Bivariate testing was done using Fisher's exact and Monte Carlo estimates for the exact test. RESULTS MOI was found to vary by age with non-accidental trauma found to be the most common cause of trauma related deaths in children <1 (88.5%) and 1-4 (33.3%). MVC was the most common MOI in children >5 y, with 68.4% in the 5-9, 34.4% in the 10-14, and 45.8% in the 15-18 age group. The majority of fatalities resulted from a preventable injury (P < 0.0001) in the younger children with a negative association as age increased: 92.3% <1, 53.3% in 1-4, 36.8% in 5-9, 46.9% in 10-14 and 48.6% in 15-18. Of the preventable injuries, non-accidental trauma was the most common MOI in children <5, while GSW was the most common MOI in children >10. CONCLUSIONS This study demonstrates many pediatric fatalities are the result of a preventable traumatic injury. This data can guide focused traumatic injury prevention efforts.
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Affiliation(s)
- Samara L Lewis
- The University of Oklahoma Health Sciences Center, Department of Surgery, Oklahoma City, Oklahoma.
| | - Heather Liebe
- Oklahoma Children's Hospital at OU Health, Department of Pediatric Surgery, Oklahoma City, Oklahoma
| | - Christopher Jeffery
- The University of Oklahoma Health Sciences Center, Department of Surgery, Oklahoma City, Oklahoma
| | - Rohan Sebastian
- The University of Oklahoma Health Sciences Center, Department of Surgery, Oklahoma City, Oklahoma
| | - Kenneth E Stewart
- The University of Oklahoma Health Sciences Center, Department of Surgery, Oklahoma City, Oklahoma
| | - Zoona Sarwar
- The University of Oklahoma Health Sciences Center, Department of Surgery, Oklahoma City, Oklahoma
| | - Laura Gamino
- Oklahoma Children's Hospital at OU Health, Department of Pediatric Surgery, Oklahoma City, Oklahoma
| | - Jeremy J Johnson
- Oklahoma Children's Hospital at OU Health, Department of Pediatric Surgery, Oklahoma City, Oklahoma
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5
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Counting the costs of trauma: the need for a new paediatric injury severity score. THE LANCET. CHILD & ADOLESCENT HEALTH 2021; 5:391-392. [PMID: 34019790 PMCID: PMC9764975 DOI: 10.1016/s2352-4642(21)00132-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 12/24/2022]
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Kulshrestha S, Dligach D, Joyce C, Baker MS, Gonzalez R, O’Rourke AP, Glazer JM, Stey A, Kruser JM, Churpek MM, Afshar M. Prediction of severe chest injury using natural language processing from the electronic health record. Injury 2021; 52:205-212. [PMID: 33131794 PMCID: PMC7856032 DOI: 10.1016/j.injury.2020.10.094] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/02/2020] [Accepted: 10/23/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma injury severity scores are currently calculated retrospectively from the electronic health record (EHR) using manual annotation by certified trauma coders. Natural language processing (NLP) of clinical documents in the EHR may enable automated injury scoring. We hypothesize that NLP with machine learning can discriminate between cases of severe and non-severe injury to the thorax after trauma. METHODS Clinical documents from a trauma center were examined between 2014 and 2018. Severe chest injury was defined as a thorax abbreviated injury score (AIS) >2 and served as the reference standard for supervised learning. Free text unigrams and concept unique identifiers (CUIs) from the Unified Medical Language Systems (UMLS) were extracted from clinical documents collected at one hour, four hours, and eight hours after patient arrival to the emergency department. Logistic regression models with elastic net regularization were tuned to maximize area under the receiver operating characteristic curve (AUROC) using 10-fold cross-validation on the training dataset (80%) and tested on a hold-out 20% dataset. RESULTS There were 6,891 traumas that met inclusion criteria. The complete data corpus consisted of 473,694 documents. Models trained using the first hour of data had a mean AUROC of 0.88 (95%CI [0.86, 0.89]); model discrimination and reclassification from the first hour significantly improved after eight hours with a mean AUROC of 0.94 (95%CI [0.93, 0.95]). Performance of models using CUIs were similar to unigrams (p>0.05). Models demonstrated excellent clinical face validity. CONCLUSIONS Both CUIs and unigrams demonstrated excellent discrimination in predicting severity of chest injury using the first eight hours of clinical documents. Our model demonstrates that automated anatomical injury scoring is feasible and may be used for aggregation of data for trauma research and quality programs.
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Affiliation(s)
- Sujay Kulshrestha
- Burn and Shock Trauma Research Institute, Loyola University Chicago, CTRE Building 115, Room 315, 2160 South 1st Avenue, Maywood, IL, USA,Department of Surgery, Loyola University Medical Center, EMS Building 110, Room 3210, 2160 South 1st Avenue, Maywood, IL, USA
| | - Dmitriy Dligach
- Center for Health Outcomes and Informatics Research, Health Sciences Division, Loyola University Chicago, CTRE Building 115, Room 126, 2160 South 1st Avenue, Maywood, IL, USA,Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, 2160 South 1st Avenue, Maywood, IL, USA,Department of Computer Science, Loyola University Chicago, 1052 West Loyola Avenue, Chicago, IL, USA
| | - Cara Joyce
- Center for Health Outcomes and Informatics Research, Health Sciences Division, Loyola University Chicago, CTRE Building 115, Room 126, 2160 South 1st Avenue, Maywood, IL, USA,Department of Public Health Sciences, Stritch School of Medicine, Loyola University Chicago, 2160 South 1st Avenue, Maywood, IL, USA
| | - Marshall S. Baker
- Department of Surgery, Loyola University Medical Center, EMS Building 110, Room 3210, 2160 South 1st Avenue, Maywood, IL, USA,Edward Hines Jr. Veterans Affairs Hospital, 5000 South Fifth Avenue, Hines, IL, USA
| | - Richard Gonzalez
- Burn and Shock Trauma Research Institute, Loyola University Chicago, CTRE Building 115, Room 315, 2160 South 1st Avenue, Maywood, IL, USA,Department of Surgery, Loyola University Medical Center, EMS Building 110, Room 3210, 2160 South 1st Avenue, Maywood, IL, USA
| | - Ann P. O’Rourke
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, MC 3236, Madison, WI, USA
| | - Joshua M. Glazer
- Department of Emergency Medicine, University of Wisconsin, 800 University Bay Drive, Suite 310, MC 9123, Madison, WI, USA
| | - Anne Stey
- Division of Trauma and Surgical Critical Care, Department of Surgery, Northwestern University, 76 North St. Clair Street, Suite 650, Chicago, IL, USA
| | - Jacqueline M. Kruser
- Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University, 633 North St. Clair Street, 20th Floor, McGaw M-335, Chicago, IL, USA,Department of Medical Social Sciences, Northwestern University, 633 North St. Clair Street, 19th Floor, Chicago, IL, USA
| | - Matthew M. Churpek
- Department of Medicine, University of Wisconsin, 8007 Excelsior Drive, Madison, WI, USA
| | - Majid Afshar
- Center for Health Outcomes and Informatics Research, Health Sciences Division, Loyola University Chicago, CTRE Building 115, Room 126, 2160 South 1st Avenue, Maywood, IL, USA,Department of Health Informatics and Data Science, Loyola University Chicago, 2160 South First Avenue, Maywood, IL, USA
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7
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Keneally RJ, Meyers BA, Shields CH, Ricca R, Creamer KM. Pediatric Thoracic Trauma Mortality in Iraq and Afghanistan Compared to the United States National Trauma Data Bank. Mil Med 2021; 187:e338-e342. [PMID: 33506871 DOI: 10.1093/milmed/usab020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/08/2020] [Accepted: 01/18/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The authors compared pediatric thoracic patients in the Joint Theatre Trauma Registry (JTTR) to those in the National Trauma Data Bank (NTDB) to assess differences in patient mortality rates and mortality risk accounting for age, injury patterns, and injury severity. MATERIALS AND METHODS Patients less than 19 years of age with thoracic trauma were identified in both the JTTR and NTDB. Multiple logistic regression, χ2, Student's t-test, or Mann-Whitney U test were used as indicated to compare the two groups. RESULTS Pediatric thoracic trauma patients seen in Iraq and Afghanistan (n = 955) had a significantly higher mortality rate (15.1 vs. 6.0%, P <.01) than those in the NTDB (n = 9085). After controlling for covariates between the JTTR and the NTDB, there was no difference in mortality (odds ratio for mortality for U.S. patients was 0.74, 95% CI 0.52-1.06, P = .10). The patients seen in Iraq or Afghanistan were significantly younger (8 years old, interquartile ratio (IQR) 2-13 vs. 15, IQR 10-17, P <.01) had greater severity of injuries (injury severity score 17, IQR 12-26 vs. 12, IQR 8-22, P <.01), had significantly more head injuries (29 vs. 14%, P <.01), and over half were exposed to a blast. DISCUSSION Pediatric patients with thoracic trauma in Iraq and Afghanistan in the JTTR had similar mortality rates compared to the civilian population in the NTDB after accounting for confounding covariates. These findings indicate that deployed military medical professionals are providing comparable quality of care in extremely challenging circumstances. This information has important implications for military preparedness, medical training, and casualty care.
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Affiliation(s)
- Ryan J Keneally
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC 20052, USA.,Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brittney A Meyers
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC 20052, USA
| | - Cynthia H Shields
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Robert Ricca
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Kevin M Creamer
- Department of Pediatrics, The George Washington University, Washington, DC 20052, USA
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Miller JP, O' Reilly GM, Mackelprang JL, Mitra B. Trauma in adults experiencing homelessness. Injury 2020; 51:897-905. [PMID: 32147144 DOI: 10.1016/j.injury.2020.02.086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/16/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Homeless individuals suffer a greater burden of health problems than the general population. This study aimed to describe the epidemiology of physical trauma among homeless patients presenting to an urban major trauma center and to ascertain any differences in the nature, injury severity and outcomes among homeless compared to domiciled patients. METHODS A retrospective matched cohort study that included adults who met inclusion criteria for The Alfred Hospital Trauma Registry between 01 July 2010 and 31 March 2017 was conducted. Primary homelessness was identified using the International Statistical Classification of Diseases, 10th Revision Coding Z59.0 and/or 'No fixed abode' address data. Homeless and domiciled patients were matched at a 1:2 ratio on age, sex, month and year of injury. The primary outcome variable was the Injury Severity Score (ISS). Secondary outcomes were hospital length of stay (LOS), mortality, emergency department (ED) disposition, hospital disposition, discharge processes and trauma registry recidivism. RESULTS Of 25,920 cases in the trauma registry, 147 (0.6%) were identified as homeless, comprising 131 unique homeless individuals who were matched with 262 domiciled patients. The median (Inter-Quartile Range) ISS among homeless patients was 5(2-10), compared to 9(4-17) for domiciled patients (p < 0.001). Homeless patients had significantly lower odds of sustaining an injury with ISS>12 (OR 0.5, 95% CI: 0.3-0.8, p = 0.001). Homeless patients were treated more often than domiciled patients for assault (32.1% vs 9.5%), intentional self-harm (10.7% vs 2.7%), and penetrating injury (16.0% vs 6.5%). Homeless patients had higher rates of psychiatry admissions (9.2% vs 0.8%), positive blood alcohol concentration (30.5% vs 13.7%), and higher odds of discharging against medical advice (DAMA)(OR 2.0, 95% CI: 1.1-3.6 p = 0.02). There were no differences in LOS (p = 0.51), mortality (p = 0.19), ED disposition (p = 0.64) or trauma registry recidivism (p = 0.09). CONCLUSION Among injured patients who presented at an urban trauma center, homelessness was associated with higher odds of assault, intentional self-harm, penetrating injury, psychiatry admissions, DAMA but lower ISS than domiciled patients. Variable definitions of homelessness and lack of standardized documentation in the medical record should be addressed to ensure these vulnerable patients are identified and linked with peripheral services.
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Affiliation(s)
| | - Gerard M O' Reilly
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | | | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
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9
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Tunthanathip T, Phuenpathom N. Impact of Road Traffic Injury to Pediatric Traumatic Brain Injury in Southern Thailand. J Neurosci Rural Pract 2019; 8:601-608. [PMID: 29204022 PMCID: PMC5709885 DOI: 10.4103/jnrp.jnrp_381_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Motor vehicle is a major transportation in Southern Thailand as the result of road traffic injury and death. Consequently, severe disability and mortality in pediatric traumatic brain injury (TBI) were observed from traffic accident, particularly motorcycle accident. To identify the risk of intracranial injury in children, the association of treatment outcome with various factors including mechanisms of injury, clinical characteristics, and intracranial pathology can be assessed. Materials and Methods This was a retrospective study conducted on children, who were younger than 15 years old with TBI and were enrolled from 2004 to 2015. Several clinically relevant issues were reviewed and statistically analyzed. Results A total of 948 casualties were enrolled. Compared with falling down, the motorcycle accident was significantly associated with intracranial injury (odds ratio 1.73, 95% confidence interval [CI] 1.08-2.76). Other factors associated with intracranial injury were hemiparesis (odds ratio 5.69, 95% CI 1.44-22.36), positive of basal skull fracture signs (odds ratio 15.66, 95% CI 3.44-71.28), and fixed reaction to light of both pupils (odds ratio 5.74, 95% CI 1.71-19.23). Mortality found in thirty cases (3.2%). Furthermore, the risk of death correlated with motorcycle accident (P = 0.02) and severe head injury (P < 0.001). Neurosurgical intervention was not associated with outcome, but severe head injury, hemorrhagic shock, epidural, and subdural hematoma were impact factors. Conclusion The findings demonstrate road traffic injury, especially motorcycle accident leading to brain injury and death. Prevention program is a necessary key to decrease mortality and disability in pediatric TBI.
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Affiliation(s)
- Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
| | - Nakornchai Phuenpathom
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Songklanagarind Hospital, Prince of Songkla University, Songkhla, Thailand
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Greenan K, Taylor SL, Fulkerson D, Shahlaie K, Gerndt C, Krueger EM, Zwienenberg M. Selection of children with ultra-severe traumatic brain injury for neurosurgical intervention. J Neurosurg Pediatr 2019; 23:670-679. [PMID: 30952132 DOI: 10.3171/2019.1.peds18293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 01/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A recent retrospective study of severe traumatic brain injury (TBI) in pediatric patients showed similar outcomes in those with a Glasgow Coma Scale (GCS) score of 3 and those with a score of 4 and reported a favorable long-term outcome in 11.9% of patients. Using decision tree analysis, authors of that study provided criteria to identify patients with a potentially favorable outcome. The authors of the present study sought to validate the previously described decision tree and further inform understanding of the outcomes of children with a GCS score 3 or 4 by using data from multiple institutions and machine learning methods to identify important predictors of outcome. METHODS Clinical, radiographic, and outcome data on pediatric TBI patients (age < 18 years) were prospectively collected as part of an institutional TBI registry. Patients with a GCS score of 3 or 4 were selected, and the previously published prediction model was evaluated using this data set. Next, a combined data set that included data from two institutions was used to create a new, more statistically robust model using binomial recursive partitioning to create a decision tree. RESULTS Forty-five patients from the institutional TBI registry were included in the present study, as were 67 patients from the previously published data set, for a total of 112 patients in the combined analysis. The previously published prediction model for survival was externally validated and performed only modestly (AUC 0.68, 95% CI 0.47, 0.89). In the combined data set, pupillary response and age were the only predictors retained in the decision tree. Ninety-six percent of patients with bilaterally nonreactive pupils had a poor outcome. If the pupillary response was normal in at least one eye, the outcome subsequently depended on age: 72% of children between 5 months and 6 years old had a favorable outcome, whereas 100% of children younger than 5 months old and 77% of those older than 6 years had poor outcomes. The overall accuracy of the combined prediction model was 90.2% with a sensitivity of 68.4% and specificity of 93.6%. CONCLUSIONS A previously published survival model for severe TBI in children with a low GCS score was externally validated. With a larger data set, however, a simplified and more robust model was developed, and the variables most predictive of outcome were age and pupillary response.
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Affiliation(s)
- Krista Greenan
- 1Department of Neurological Surgery, University of California, Davis.,3Department of Pediatric Neurosurgery, University of Colorado, Aurora, Colorado; and
| | - Sandra L Taylor
- 2Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, California
| | - Daniel Fulkerson
- 4Department of Neurological Surgery, Goodman Campbell Brain and Spine, Riley Hospital for Children, Indiana University, Indianapolis, Indiana
| | - Kiarash Shahlaie
- 1Department of Neurological Surgery, University of California, Davis
| | - Clayton Gerndt
- 1Department of Neurological Surgery, University of California, Davis
| | - Evan M Krueger
- 3Department of Pediatric Neurosurgery, University of Colorado, Aurora, Colorado; and
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Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury 2019; 50:142-148. [PMID: 30270009 DOI: 10.1016/j.injury.2018.09.036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 09/01/2018] [Accepted: 09/18/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma is a common indication for computed tomography (CT) in children. However, children are particularly vulnerable to CT radiation and its associated cancer risk. Identifying differences in CT usage across trauma centers and among specific populations of injured children is needed to identify where quality improvement initiatives could be implemented in order to reduce excess radiation exposure to children. We evaluated computed tomography (CT) rates among injured children treated at pediatric (PTC), mixed (MTC), or adult trauma centers (ATC) and estimated the resulting differential in potential cancer risk. METHODS We identified children age ≤18 years with blunt injury AIS ≥2 treated from 2010 to 2013 at 130 U.S trauma centers participating in the Trauma Quality Improvement Program. CT rates were compared across center types using Chi-square analysis. Stratified analyses in children with varying injury severity, mechanism, and age were performed. We estimated the impact of differential rates of CT scans on cancer risk using published attributable risks. RESULTS Among 59,010 children identified, CT rates were higher among injured children treated at ATC and MTC versus PTC. Findings were consistent after stratified analyses and were most striking in children with chest and abdomen/pelvis CT, adolescent age, low injury severity and fall injury mechanism. We estimated that for every 100,000 injured children, imaging practices in ATC and MTC would lead to an additional 17 and 16 lifetime cancers, respectively, when compared to PTC. CONCLUSION CT use among injured children is higher at ATC and MTC compared to PTC. Children with low injury severity, fall injury mechanism, and adolescent age are most vulnerable to differential imaging practices across centers. Quality improvement initiatives aimed at reducing heterogeneity in CT usage across trauma centers are required to mitigate pediatric radiation exposure and cancer risk.
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Coons BE, Tam S, Rubsam J, Stylianos S, Duron V. High volume crystalloid resuscitation adversely affects pediatric trauma patients. J Pediatr Surg 2018; 53:2202-2208. [PMID: 30072215 DOI: 10.1016/j.jpedsurg.2018.07.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 06/27/2018] [Accepted: 07/12/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Aggressive fluid resuscitative strategies have been the cornerstone of early trauma management for decades. However, recent prospective adult studies have challenged this practice, underlining the detrimental effect of positive fluid balance on cardiopulmonary function. Fluid overload has been associated with impaired oxygenation and morbidity in critically ill adults, but data is lacking in pediatric trauma patients. METHODS We completed a retrospective chart review of all pediatric trauma patients 0-18 years old admitted to a level 1 trauma center from January 2013 to December 2015. Four patient cohorts were established based on volume of fluid administered: <20 ml/kg/day, 20-40 ml/kg/day, 40-60 ml/kg/day, and > 60 ml/kg/day. The primary outcome was death. Secondary outcomes included the number of days on the ventilator, intensive care unit length of stay (ICU LOS), overall length of stay (LOS), number of days nil per os (NPO) as an indicator of ileus, and incidence of bloodstream infection and/or surgical site infection. RESULTS The mean volume of fluid administered over the first 24 h was 41 ml/kg/day, and 28 ml/kg/day over the first 48 h. ICU length of stay and overall length of stay were increased in patients who received more than 60 ml/kg/day in the first 24 h of their hospitalization. Furthermore, ventilator use, ICU length of stay, overall length of stay, and time to resumption of a regular diet were all increased in patients who received >60 ml/kg/day over 48 h. CONCLUSIONS Early administration of high volumes of crystalloid fluid greater than 60 ml/kg/day significantly correlates with pulmonary complications, days NPO, and hospital length of stay. These results span the first 48 h of a patient's hospital stay and should encourage surgical care providers to exercise judicious use of crystalloid fluid administration in the trauma bay, ICU, and floor. TYPE OF STUDY Therapeutic. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Barbara E Coons
- Columbia University Department of Surgery, New York-Presbyterian Hospital, Milstein Hospital Building, 7GS 313, 177 Fort Washington Avenue, New York, NY 10032.
| | - Sophia Tam
- Columbia University Department of Surgery, New York-Presbyterian Hospital, Milstein Hospital Building, 7GS 313, 177 Fort Washington Avenue, New York, NY 10032.
| | - Jeanne Rubsam
- Morgan Stanley Children's Hospital/New York-Presbyterian, Division of Pediatric Surgery, Columbia University College of Physicians & Surgeons, 3959 Broadway, CHN 215, New York, NY 10032.
| | - Steven Stylianos
- Morgan Stanley Children's Hospital/New York-Presbyterian, Division of Pediatric Surgery, Columbia University College of Physicians & Surgeons, 3959 Broadway, CHN 215, New York, NY 10032.
| | - Vincent Duron
- Morgan Stanley Children's Hospital/New York-Presbyterian, Division of Pediatric Surgery, Columbia University College of Physicians & Surgeons, 3959 Broadway, CHN 215, New York, NY 10032.
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Meltzer JA, Stone ME, Reddy SH, Silver EJ. Association of Whole-Body Computed Tomography With Mortality Risk in Children With Blunt Trauma. JAMA Pediatr 2018; 172:542-549. [PMID: 29630685 PMCID: PMC6137533 DOI: 10.1001/jamapediatrics.2018.0109] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Although several studies have demonstrated an improvement in mortality for injured adults who receive whole-body computed tomography (WBCT), it is unclear whether children experience the same benefit. OBJECTIVE To determine whether emergent WBCT is associated with lower mortality among children with blunt trauma compared with a selective CT approach. DESIGN, SETTING, AND PARTICIPANTS A retrospective, multicenter cohort study was conducted from January 1, 2010, to December 31, 2014, using data from the National Trauma Data Bank on children aged 6 months to 14 years with blunt trauma who received an emergent CT scan in the first 2 hours after emergency department arrival. Data analysis was conducted from February 2 to December 29, 2017. EXPOSURES Patients were classified as having WBCT if they received CT head, CT chest, and CT abdomen/pelvis scans in the first 2 hours and as having a selective CT if they did not receive all 3 scans. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality in the 7 days after ED arrival. To adjust for potential confounding, propensity score weighting was used. Subgroup analyses were performed for those with the highest mortality risk (ie, occupants and pedestrians involved in motor vehicle crashes, children with a Glasgow Coma Scale score lower than 9, children with hypotension, and those admitted to the intensive care unit). RESULTS Of the 42 912 children included in the study (median age [interquartile range], 9 [5-12] years; 27 861 [64.9%] boys), 8757 (20.4%) received a WBCT. Overall, 405 (0.9%) children died within 7 days. After adjusting for the propensity score, children who received WBCT had no significant difference in mortality compared with those who received selective CT (absolute risk difference, -0.2%; 95% CI, -0.6% to 0.1%). All subgroup analyses similarly showed no significant association between WBCT and mortality. CONCLUSIONS AND RELEVANCE Among children with blunt trauma, WBCT, compared with a selective CT approach, was not associated with lower mortality. These findings do not support the routine use of WBCT for children with blunt trauma.
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Affiliation(s)
- James A. Meltzer
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York,Division of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Melvin E. Stone
- Division of Trauma, Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Srinivas H. Reddy
- Division of Trauma, Department of Surgery, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Ellen J. Silver
- Department of Pediatrics, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Schoell SL, Weaver AA, Talton JW, Barnard RT, Baker G, Stitzel JD, Zonfrillo MR. Functional outcomes of motor vehicle crash thoracic injuries in pediatric and adult occupants. TRAFFIC INJURY PREVENTION 2018; 19:280-286. [PMID: 29185785 PMCID: PMC6233316 DOI: 10.1080/15389588.2017.1409894] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/21/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Characterization of the severity of injury should account for both mortality and disability. The objective of this study was to develop a disability metric for thoracic injuries in motor vehicle crashes (MVCs) and compare the functional outcomes between the pediatric and adult populations. METHODS Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank for the most frequently occurring Abbreviated Injury Scale (AIS) 2-5 thoracic injuries. Occupants with thoracic injury were classified as disabled or not disabled based on the FIM scale, and comparisons were made between the following age groups: pediatric, adult, middle-aged, and older occupants (ages 7-18, 19-45, 46-65, and 66+, respectively). For each age group, DR was calculated by dividing the number of patients who were disabled and sustained a given injury by the number of patients who sustained a given injury. To account for the effect of higher severity co-injuries, a maximum AIS adjusted DR (DRMAIS) was also calculated for each injury. DR and DRMAIS could range from 0 to 100% disability risk. RESULTS The mean DRMAIS for MVC thoracic injuries was 20% for pediatric occupants, 22% for adults, 29% for middle-aged adults, and 43% for older adults. Older adults possessed higher DRMAIS values for diaphragm laceration/rupture, heart laceration, hemo/pneumothorax, lung contusion/laceration, and rib and sternum fracture compared to the other age groups. The pediatric population possessed a higher DRMAIS value for flail chest compared to the other age groups. CONCLUSION Older adults had significantly greater overall disability than each of the other age groups for thoracic injuries. The developed disability metrics are important in quantifying the significant burden of injuries and loss of quality life years. Such metrics can be used to better characterize severity of injury and further the understanding of age-related differences in injury outcomes, which can influence future age-specific modifications to AIS.
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Affiliation(s)
- Samantha L. Schoell
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ashley A. Weaver
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jennifer W. Talton
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, NC, USA
| | - Ryan T. Barnard
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, NC, USA
| | - Gretchen Baker
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joel D. Stitzel
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mark R. Zonfrillo
- Alpert Medical School of Brown University and Hasbro Children’s Hospital, Providence, RI, USA
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Abstract
OBJECTIVES We analyzed a prospective database of pediatric traumatic brain injury patients to identify predictors of outcome and describe the change in function over time. We hypothesized that neurologic status at hospital discharge would not reflect the long-term neurologic recovery state. DESIGN This is a descriptive cohort analysis of a single-center prospective database of pediatric traumatic brain injury patients from 2001 to 2012. Functional outcome was assessed at hospital discharge, and the Glasgow Outcome Scale Extended Pediatrics or Glasgow Outcome Scale was assessed on average at 15.8 months after injury. SETTING Children's Medical Center Dallas, a single-center PICU and Level 1 Trauma Center. PATIENTS Patients, 0-17 years old, with complicated-mild/moderate or severe accidental traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Dichotomized long-term outcome was favorable in 217 of 258 patients (84%), 80 of 82 patients (98%) with complicated-mild/moderate injury and 133 of 172 severe patients (77%). In the bivariate analysis, younger age, motor vehicle collision as a mechanism of injury, intracranial pressure monitor placement, cardiopulmonary resuscitation at scene or emergency department, increased hospital length of stay, increased ventilator days (all with p < 0.01) and occurrence of seizures (p = 0.03) were significantly associated with an unfavorable outcome. In multiple regression analysis, younger age (p = 0.03), motor vehicle collision (p = 0.01), cardiopulmonary resuscitation (p < 0.01), and ventilator days (p < 0.01) remained significant. Remarkably, 28 of 60 children (47%) with an unfavorable Glasgow Outcome Scale at hospital discharge improved to a favorable outcome. In severe patients with an unfavorable outcome at hospital discharge, younger age was identified as a risk factor for remaining in an unfavorable condition (p = 0.1). CONCLUSIONS Despite a poor neurologic status at hospital discharge, many children after traumatic brain injury will significantly improve at long-term assessment. The factors most associated with outcomes were age, cardiopulmonary resuscitation, motor vehicle collision, intracranial pressure placement, days on a ventilator, hospital length of stay, and seizures. The factor most associated with improvement from an unfavorable neurologic status at discharge was being older.
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Weaver AA, Schoell SL, Talton JW, Barnard RT, Stitzel JD, Zonfrillo MR. Functional outcomes of thoracic injuries in pediatric and adult occupants. TRAFFIC INJURY PREVENTION 2018; 19:S195-S198. [PMID: 29584488 PMCID: PMC6776991 DOI: 10.1080/15389588.2018.1426927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To develop a disability metric for motor vehicle crash (MVC) thoracic injuries and compare functional outcomes between pediatric and adult populations. METHODS Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank (NTDB) for the top 95% most frequently occurring AIS 2, 3, 4, and 5 thoracic injuries in NASS-CDS 2000-2011. The NTDB contains a truncated form of the FIM score, including three items (self-feed, locomotion, and verbal expression), each graded from full functional dependence to full functional independence. Pediatric (ages 7-18 years), adult (19-45), middle-aged adult (46-65), and older adult (66+) MVC occupants were classified as disabled or not disabled based on the FIM scale. The DR was calculated for each injury within each age group by dividing the number of patients who were disabled that sustained the specific injury by the number of patients who sustained the specific injury. To account for the impact of more severe co-injuries, a maximum Abbreviated Injury Scale (MAIS) adjusted DR (DRMAIS) was also calculated. DR and DRMAIS could range from 0 (0% disability risk) to 1 (100% disability risk). RESULTS The mean DRMAIS for MVC thoracic injuries was 20% for pediatric occupants, 22% for adults, 29% for middle-aged adults, and 43% for older adults. Older adults possessed higher DRMAIS values for diaphragm laceration/rupture, heart laceration, hemo/pneumothorax, lung contusion/laceration, rib fracture, and sternum fracture compared to the other age groups. The pediatric population possessed a higher DRMAIS value for flail chest compared to the other age groups. CONCLUSIONS Older adults had significantly greater overall disability than each of the other age groups for thoracic injuries. The developed disability metrics are important in quantifying the significant burden of injuries and loss of quality life years. Such metrics can be used to better characterize severity of injury and further the understanding of age-related differences in injury outcomes, which can impact future age-specific modifications to AIS.
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Affiliation(s)
- Ashley A. Weaver
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Samantha L. Schoell
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jennifer W. Talton
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, NC, USA
| | - Ryan T. Barnard
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston-Salem, NC, USA
| | - Joel D. Stitzel
- Virginia Tech-Wake Forest University Center for Injury Biomechanics, Winston-Salem, NC, USA
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mark R. Zonfrillo
- Alpert Medical School of Brown University and Hasbro Children’s Hospital, Providence, RI, USA
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17
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Abstract
OBJECTIVES To determine the rate, etiology, and timing of unplanned and planned hospital readmissions and to identify risk factors for unplanned readmission in children who survive a hospitalization for trauma. DESIGN Multicenter retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information System database, 2007-2012. SETTING Twenty-nine U.S. children's hospitals. PATIENTS 51,591 children (< 18 yr at admission) who survived more than or equal to a 2-day hospitalization for trauma. MEASUREMENTS AND MAIN RESULTS The primary outcome was unplanned readmission within 1 year of discharge from the injury hospitalization. Secondary outcomes included any readmission, reason for readmission, time to readmission, and number of readmissions within 1 year of discharge. The primary exposure groups were isolated traumatic brain injury, both traumatic brain injury and other injury, or nontraumatic brain injury only. We hypothesized a priori that any traumatic brain injury would be associated with both planned and unplanned hospital readmission. We used All Patient Refined Diagnosis Related Groups codes to categorize readmissions by etiology and planned or unplanned. Overall, 4,301/49,982 of the patients (8.6%) with more than or equal to 1 year of observation time were readmitted to the same hospital within 1 year. Many readmissions were unplanned: 2,704/49,982 (5.4%) experienced an unplanned readmission in the first year. The most common reason for unplanned readmission was infection (22%), primarily postoperative or posttraumatic infection (38% of readmissions for infection). Traumatic brain injury was associated with lower odds of unplanned readmission in multivariable analyses. Seizure or RBC transfusion during the index hospitalization were the strongest predictors of unplanned, earlier, and multiple readmissions. CONCLUSIONS Many survivors of pediatric trauma experience unplanned, and potentially preventable, hospital readmissions in the year after discharge. Identification of those at highest risk of readmission can guide targeted in-hospital or postdischarge interventions.
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Affiliation(s)
- Aline B. Maddux
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
| | - Peter E. DeWitt
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Peter M. Mourani
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
| | - Tellen D. Bennett
- Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital Colorado, Aurora, CO
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
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Avraham JB, Bhandari M, Frangos SG, Levine DA, Tunik MG, DiMaggio CJ. Epidemiology of paediatric trauma presenting to US emergency departments: 2006-2012. Inj Prev 2017; 25:136-143. [PMID: 29056586 DOI: 10.1136/injuryprev-2017-042435] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. METHODS We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006-2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. RESULTS There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15-19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. CONCLUSIONS This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.
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Affiliation(s)
- Jacob B Avraham
- Department of Surgery, New York University School of Medicine, New York, NY, USA
| | - Misha Bhandari
- Department of Surgery, New York University School of Medicine, New York City, New York, USA.,Department of Emergency Medicine, New York Presbyterian, The University Hospital of Columbia and Cornell, New York, NY
| | - Spiros G Frangos
- Department of Surgery, Division of Acute Care and Trauma Surgery, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA
| | - Deborah A Levine
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA.,Ronald O Perelman Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA
| | - Michael G Tunik
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA.,Ronald O Perelman Department of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA
| | - Charles J DiMaggio
- Department of Surgery, Division of Acute Care and Trauma Surgery, New York University School of Medicine/Bellevue Hospital Center, New York City, New York, USA.,Population Health, New York University School of Medicine, New York, NY, USA
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20
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Abstract
BACKGROUND Mortality rates among children in motor vehicle crashes (MVCs) are typically low; however, nonfatal injuries can vary in severity by imposing differing levels of short- and long-term disability. To better discriminate the severity of nonfatal MVC injuries, a pediatric-specific disability risk (DR) metric was created. METHODS The National Automotive Sampling System 2000 to 2011 was used to define the top 95% most common Abbreviated Injury Scale (AIS) 2+ injuries among pediatric MVC occupants. Functional Independence Measure scores were abstracted from the National Trauma Data Bank 2002 to 2006. Multiple imputation was used to account for missing data. The DR and coinjury-adjusted DR (DRMAIS) of the most common AIS 2+ MVC-induced injuries were calculated for 7-year-old to 18-year-old children by determining the proportion of those disabled after an injury to those sustaining the injury. DR and DRMAIS values ranged from 0 to 1, representing 0% to 100% DR. RESULTS The mean DR and DRMAIS of all injuries were 0.290 and 0.191, respectively. DR and DRMAIS were greatest for injuries to the head (DR, 0.340; DRMAIS, 0.279), thorax (DR, 0.320; DRMAIS, 0.233), and spine (DR, 0.315; DRMAIS, 0.200). The mean DR and DRMAIS increased with increasing AIS severity but there was significant variation and overlapping values across AIS severity levels. Comparison of DRMAIS to coinjury-adjusted mortality risk (MRMAIS) revealed that among 118 injuries with MRMAIS of 0.000, DRMAIS ranged from 0.000 to 0.429. CONCLUSION Incorporation of DR metrics into injury severity metrics may improve the ability to distinguish between the severity of different nonfatal injuries. This is especially crucial in the pediatric population where permanent disability can result in a high number of years lost due to disability. The accuracy of such severity metrics is crucial to the success of pediatric triage algorithms such as Advanced Automatic Crash Notification algorithms. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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21
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Systematic review and need assessment of pediatric trauma outcome benchmarking tools for low-resource settings. Pediatr Surg Int 2017; 33:299-309. [PMID: 27873009 DOI: 10.1007/s00383-016-4024-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Trauma is a leading cause of mortality and disability in children worldwide. The World Health Organization reports that 95% of all childhood injury deaths occur in Low-Middle-Income Countries (LMIC). Injury scores have been developed to facilitate risk stratification, clinical decision making, and research. Trauma registries in LMIC depend on adapted trauma scores that do not rely on investigations that require unavailable material or human resources. We sought to review and assess the existing trauma scores used in pediatric patients. Our objective is to determine their wideness of use, validity, setting of use, outcome measures, and criticisms. We believe that there is a need for an adapted trauma score developed specifically for pediatric patients in low-resource settings. MATERIALS AND METHODS A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. We constructed a search strategy in collaboration with a senior hospital librarian. Multiple databases were searched, including Embase, Medline, and the Cochrane Central Register of Controlled Trials. Articles were selected based on predefined inclusion criteria by two reviewers and underwent qualitative analysis. RESULTS The scores identified are suboptimal for use in pediatric patients in low-resource settings due to various factors, including reliance on precise anatomic diagnosis, physiologic parameters maladapted to pediatric patients, or laboratory data with inconsistent accessibility in LMIC. CONCLUSION An important gap exists in our ability to simply and reliably estimate injury severity in pediatric patients and predict their associated probability of outcomes in settings, where resources are limited. An ideal score should be easy to calculate using point-of-care data that are readily available in LMIC, and can be easily adapted to the specific physiologic variations of different age groups.
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Alghnam S, Alkelya M, Alfraidy M, Al-Bedah K, Albabtain IT, Alshenqeety O. Outcomes of road traffic injuries before and after the implementation of a camera ticketing system: a retrospective study from a large trauma center in Saudi Arabia. Ann Saudi Med 2017; 37:1-9. [PMID: 28151450 PMCID: PMC6148978 DOI: 10.5144/0256-4947.2017.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Road traffic injuries (RTIs) are the third leading cause of death in Saudi Arabia. Because speed is a major risk factor for severe crash-related injuries, a camera ticketing system was implemented countrywide in mid-2010 by the traffic police in an effort to improve traffic safety. There are no published studies on the effects of the system in Saudi Arabia. OBJECTIVE To examine injury severity and associated mortality at a large trauma center before and after the implementation of the ticketing system. DESIGN Retrospective, analytical. SETTING Trauma center of a tertiary care center in Riyadh. PATIENTS AND METHODS The study included all trauma registry patients seen in the emergency department for a crash-related injury (automobile occupants, pedestrians, or motorcyclists) between January 2005 and December 2014. Associations with outcome measures were assessed by univariate and multivariate methods. MAIN OUTCOME MEASURE(S) Injury severity score (ISS), Glasgow coma scale (GCS) and mortality. RESULTS The study included all trauma registry patients seen in the emergency department for a crash-related injury. All health outcomes improved in the period following implementation of the ticketing system. Following implementation, ISS scores decreased (-3.1, 95% CI -4.6, -1.6) and GCS increased (0.47, 95% CI 0.08, 0.87) after adjusting for other covariates. The odds of death were 46% lower following implementation than before implementation. When the data were log-transformed to account for skewed data distributions, the results remained statistically significant. CONCLUSIONS This study suggests positive health implications following the implementation of the camera ticketing system. Further investment in public health interventions is warranted to reduce preventable RTIs. LIMITATIONS The study findings represent a trauma center at a single hospital in Riyadh, which may not generalize to the Saudi population.
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Affiliation(s)
- Suliman Alghnam
- Dr. Suliman Abdulah Alghnam, King Abdulah International Research Center (KAIMRC), Population Health, PO Box 22490,, Riyadh, 11426, Saudi Arabia,, T: 0539468887, , ORCID: http://orcid.org/0000-0001-5817-0481
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Dreyfus J, Flood A, Cutler G, Ortega H, Kreykes N, Kharbanda A. Comparison of pediatric motor vehicle collision injury outcomes at Level I trauma centers. J Pediatr Surg 2016; 51:1693-9. [PMID: 27160431 DOI: 10.1016/j.jpedsurg.2016.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/04/2016] [Accepted: 04/10/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Examine the association of American College of Surgeons Level I pediatric trauma center designation with outcomes of pediatric motor vehicle collision-related injuries. METHODS Observational study of the 2009-2012 National Trauma Data Bank, including n=28,145 patients <18years directly transported to a Level I trauma center. Generalized estimating equations estimated odds ratios (ORs) for injury outcomes, comparing freestanding pediatric trauma centers (PTCs) with adult centers having added Level I pediatric qualifications (ATC+PTC) and general adult trauma centers (ATC). Models were stratified by age following PTC designation guidelines, and adjusted for demographic and clinical risk factors. RESULTS Analyses included n=16,643 children <15 and n=11,502 adolescents 15-17years. Among children, odds of laparotomy (OR=1.88, 95% CI 1.28-2.74) and pneumonia (OR=2.13, 95% CI 1.32-3.46) were greater at ATCs vs. freestanding PTCs. Adolescents treated at ATC+PTCs or ATCs experienced greater odds of death (OR=2.18, 95% CI 1.30-3.67; OR=1.98, 95% CI 1.37-2.85, respectively) and laparotomy (OR=4.33, 95% CI 1.56-12.02; OR=5.11, 95% CI 1.92-13.61, respectively). CONCLUSIONS Compared with freestanding PTCs, children treated at general ATCs experienced more complications; adolescents treated at ATC+PTCs or general ATCs had greater odds of death. Identification and sharing of best practices among Level I trauma centers may reduce variation in care and improve outcomes for children.
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Affiliation(s)
- Jill Dreyfus
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404.
| | - Andrew Flood
- Department of Research and Sponsored Programs, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Gretchen Cutler
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Henry Ortega
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Nathan Kreykes
- Department of Pediatric Surgery, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, 2525 Chicago Avenue, Minneapolis, MN 55404
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Schoell SL, Weaver AA, Talton JW, Baker G, Doud AN, Barnard RT, Stitzel JD, Zonfrillo MR. Functional outcomes of motor vehicle crash head injuries in pediatric and adult occupants. TRAFFIC INJURY PREVENTION 2016; 17 Suppl 1:27-33. [PMID: 27586099 PMCID: PMC6211837 DOI: 10.1080/15389588.2016.1201203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/07/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The objective of the study was to develop a disability-based metric for motor vehicle crash (MVC) injuries, with a focus on head injuries, and compare the functional outcomes between the pediatric and adult populations. METHODS Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System (NTDB-RDS) for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3, 4, and 5 head injuries in NASS-CDS 2000-2011. Pediatric (ages 7-18), adult (19-45), middle-aged (46-65), and older adult (66+) patients with an FIM score available who were alive at discharge and had an AIS 3, 4, or 5 injury were included in the study. The NTDB-RDS contains a truncated form of the FIM instrument, including 3 items (self-feed, locomotion, and verbal expression), each graded on a scale of 1 (full functional dependence) to 4 (full functional independence). Patients within each age group were classified as disabled or not disabled based on the FIM scale. The DR was calculated for each age group by dividing the number of patients who sustained a specific injury and were disabled by the number of patients who sustained the specific injury. To account for the impact of more severe associated coinjuries, a maximum AIS (MAIS) adjusted DR (DRMAIS) was also calculated for each injury. DR and DRMAIS ranged from 0 (0% disability risk) to 1 (100% disability risk). RESULTS An analysis of the most frequent FIM components associated with disabling MVC head injuries revealed that disability across all 3 items (self-feed, locomotion, and expression) was the most frequent for pediatric and adult patients. Only locomotion was the most frequent for middle-aged and older adults. The mean DRMAIS for MVC head injuries was 35% for pediatric patients, 36% for adults, 38% for middle-aged adults, and 44% for older adults. Further analysis was conducted by grouping the head injuries into 8 groups based on the structure of injury and injury type. The pediatric population possessed higher DRMAIS values for brain stem injuries as well as loss of consciousness injuries. Older adults possessed higher DRMAIS values for contusion/hemorrhage injuries, epidural hemorrhage, intracerebral hemorrhage, skull fracture, and subdural/subarachnoid hemorrhage. CONCLUSION At-risk populations such as pediatric and older adult patients possessed higher DRMAIS values for different head injuries. Disability in pediatric patients is critical due to loss of quality life years. Disability risk can supplement severity metrics to improve the ability of such metrics to discriminate the severity of different injuries that do not lead to death. Understanding of age-related differences in injury outcomes when compared to adults could inform future age-specific modifications to the AIS.
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Affiliation(s)
- Samantha L. Schoell
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Ashley A. Weaver
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Jennifer W. Talton
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston–Salem, North Carolina
| | - Gretchen Baker
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
| | - Andrea N. Doud
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Ryan T. Barnard
- Wake Forest School of Medicine, Division of Public Health Sciences, Winston–Salem, North Carolina
| | - Joel D. Stitzel
- Virginia Tech–Wake Forest University Center for Injury Biomechanics, Winston–Salem, North Carolina
- Wake Forest School of Medicine, Winston–Salem, North Carolina
| | - Mark R. Zonfrillo
- Alpert Medical School of Brown University and Hasbro Children’s Hospital, Providence, Rhode Island
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Logistic Regression Modeling for Evaluation of Factors Affecting Trauma Outcome in a Level I Trauma Center in Shiraz. IRANIAN RED CRESCENT MEDICAL JOURNAL 2016. [DOI: 10.5812/ircmj.33559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Park YJ, Ro YS, Shin SD, Song KJ, Lee SC, Kim YJ, Kim JY, Hong KJ, Kim JE, Kim MJ, Kim SC. Age effects on case fatality rates of injury patients by mechanism. Am J Emerg Med 2016; 34:515-20. [DOI: 10.1016/j.ajem.2015.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/14/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022] Open
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Beck H, Mittal S, Madigan D, Burd RS. Reassessing mechanism as a predictor of pediatric injury mortality. J Surg Res 2015; 199:641-6. [PMID: 26197948 PMCID: PMC4636960 DOI: 10.1016/j.jss.2015.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 05/28/2015] [Accepted: 06/17/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND The use of mechanism of injury as a predictor of injury outcome presents practical challenges because this variable may be missing or inaccurate in many databases. The purpose of this study was to determine the importance of mechanism of injury as a predictor of mortality among injured children. METHODS The records of children (<15-y-old) sustaining a blunt injury were obtained from the National Trauma Data Bank. Models predicting injury mortality were developed using mechanism of injury and injury coding using either abbreviated injury scale post-dot values (low-dimensional injury coding) or injury International Classification of Diseases, Ninth Revision codes and their two-way interactions (high-dimensional injury coding). Model performance with and without inclusion of mechanism of injury was compared for both coding schemes, and the relative importance of mechanism of injury as a variable in each model type was evaluated. RESULTS Among 62,569 records, a mortality rate of 0.9% was observed. Inclusion of mechanism of injury improved model performance when using low-dimensional injury coding but was associated with no improvement when using high-dimensional injury coding. Mechanism of injury contributed to 28% of model variance when using low-dimensional injury coding and <1% when high-dimensional injury coding was used. CONCLUSIONS Although mechanism of injury may be an important predictor of injury mortality among children sustaining blunt trauma, its importance as a predictor of mortality depends on the approach used for injury coding. Mechanism of injury is not an essential predictor of outcome after injury when coding schemes are used that better characterize injuries sustained after blunt pediatric trauma.
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Affiliation(s)
- Haley Beck
- Children’s National Medical Center, Division of Trauma and Burn Surgery, 111 Michigan Ave NW, Washington, DC 20010, USA
| | - Sushil Mittal
- Scibler Corporation, 1524 Vista Club Circle, #103, Santa Clara, CA, 95054 Santa Clara, CA 95054, USA
| | - David Madigan
- Department of Statistics, Columbia University, Room 1005 SSW, MC 4690, New York, NY 10027, USA
| | - Randall S. Burd
- Children’s National Medical Center, Division of Trauma and Burn Surgery, 111 Michigan Ave NW, Washington, DC 20010, USA
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Fulkerson DH, White IK, Rees JM, Baumanis MM, Smith JL, Ackerman LL, Boaz JC, Luerssen TG. Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr 2015; 16:410-9. [PMID: 26140392 DOI: 10.3171/2015.3.peds14679] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a "normal" outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.
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Affiliation(s)
- Daniel H Fulkerson
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Ian K White
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jacqueline M Rees
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Maraya M Baumanis
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jodi L Smith
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Laurie L Ackerman
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Joel C Boaz
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Thomas G Luerssen
- Department of Neurological Surgery, Baylor College of Medicine, Texas Children's Hospital, Pediatric Neurosurgery, Houston, Texas
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Leow JJ, Lim VW, Lingam P, Go KTS, Teo LT. Ethnic disparities in trauma mortality outcomes. World J Surg 2015; 38:1694-8. [PMID: 24510246 DOI: 10.1007/s00268-014-2459-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ethnic disparities in trauma mortality outcomes have been demonstrated in the United States according to the US National Trauma Data Bank. The aim of this study was to determine the effect of race/ethnicity on trauma mortality in Singapore. METHODS This was a retrospective review of patients aged 18-64 years with an injury severity score (ISS) ≥ 9 in the Trauma Registry of Tan Tock Seng Hospital, a 1,300-bed trauma center in Singapore, from 2006 to 2010. Chinese, Malay, and Indian patients were compared with patients of other ethnic groups. Multiple logistic regression analyses determined differences in survival rates after adjusting for demographics, anatomic and physiologic ISS and revised trauma score, mechanism or type of injury. RESULTS A total of 4,186 patients (66.4 % of the database) met the inclusion criteria. Most patients were male (76.3 %) and young (mean age 40 years). Using Chinese as the reference group, we found no statistically significant differences in unadjusted or adjusted mortality rates among the ethnic groups. Independent predictors of mortality included age [odds ratio (OR) 1.05, 95 % confidence interval (CI) 1.03-1.06, p < 0.0001], presence of severe head injury (OR 1.75, 95 % CI 1.13-2.69, p = 0.012), and increasing ISS (p < 0.0001). CONCLUSIONS Ethnicity is not an independent predictor of trauma mortality outcomes in the Singapore population. Our findings contrast with those from the United States, where race/ethnicity (Black and Hispanic) remains a strong independent risk factor for trauma mortality. This study attests to the success of the Singapore health care/trauma system in delivering the same quality of care regardless of ethnicity.
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Affiliation(s)
- Jeffrey J Leow
- Trauma Services, Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore,
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Gordon AS, Tofil N, Marullo D, Blount JP. Bihemispheric gunshot wounds: survival and long-term neuropsychological follow-up of three siblings. Childs Nerv Syst 2014; 30:1589-94. [PMID: 24798479 DOI: 10.1007/s00381-014-2429-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 04/27/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Penetrating gunshot wounds to the head (GSWH) have notoriously poor outcomes with extremely high mortality. Long-term follow-up data of affected children is scant in the medical literature. This report summarizes clinical presentation, management, and long-term outcomes from three children who survived "execution style" frontal, bihemispheric gunshot wounds with no or minimal surgical intervention. METHODS A retrospective chart review of available medical records and outcomes from standardized, validated psychological instruments was undertaken, summarized, and evaluated. RESULTS Despite bihemispheric injuries in each patient, no patient required operative intervention. Each child survived without readily evident neurologic impairment; however, the extent of impaired executive function varied widely, and severe disinhibition remains profoundly disabling in one survivor. CONCLUSIONS Bihemispheric penetrating gunshot injuries are not uniformly fatal and can occasionally be associated with long-term favorable survival; however, impaired executive function has significant potential to be profoundly disabling in these injuries.
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Affiliation(s)
- Amber S Gordon
- Department of Neurosurgery, The University of Alabama at Birmingham, 1720 2nd Ave S, Birmingham, AL, 35294, USA,
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31
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Blood alcohol content, injury severity, and adult respiratory distress syndrome. J Trauma Acute Care Surg 2014; 76:1447-55. [PMID: 24854314 DOI: 10.1097/ta.0000000000000238] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Elevated blood alcohol content (BAC) is a risk factor for injury. Associations of BAC with adult respiratory distress syndrome (ARDS) have not been conclusively established.We evaluated the association of a BAC greater than 0 mg/dL with the intermediate outcomes, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score, and their association with ARDS development. METHODS This is an observational retrospective cohort study of 26,305 primary trauma admissions to a statewide referral trauma center from July 11, 2003, to October 31, 2011. Logistic regression was performed to assess the relationship between admission BAC, ISS, GCS score, and ARDS development within 5 days of admission. RESULTS The case rate for ARDS was 5.5% (1,447). BAC greater than 0 mg/dL was associated with ARDS development in adjusted analysis (odds ratio, 1.50; 95% confidence interval [CI], 1.33-1.71; p < 0.001). High ISS (≥16) had a stronger association with ARDS development (odds ratio, 17.99; 95% CI, 15.51-20.86), as did low GCS score (≤8) (odds ratio, 8.77; 95% CI, 7.64-10.07; p < 0.001). Patients with low GCS score and high ISS had the most frequent ARDS (33.6%) and the highest case-fatality rate without ARDS (24.7%). CONCLUSION Elevated BAC is associated with ARDS development. In the analysis of alcohol exposure, ISS and GCS score occur after alcohol ingestion, making them intermediate outcomes. ISS and GCS score were strong predictors of ARDS and may be useful to identify at-risk patients. Elevated BAC may increase the frequency of the ARDS through influence on injury severity or independent molecular mechanisms, which can be discriminated only in experimental models. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Alghnam S, Alkelya M, Al-Bedah K, Al-Enazi S. Burden of traumatic injuries in Saudi Arabia: lessons from a major trauma registry in Riyadh, Saudi Arabia. Ann Saudi Med 2014; 34:291-6. [PMID: 25811200 PMCID: PMC6152567 DOI: 10.5144/0256-4947.2014.291] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In Saudi Arabia (SA), injuries are the second leading cause of death; however, little is known about their frequencies and outcomes. Trauma registries play a major role in measuring the burden on population health. This study aims to describe the population of the only hospital-based trauma registry in the country and highlight challenges and potential opportunities to improve trauma data collection and research in SA. DESIGN AND SETTINGS Using data between 2001 and 2010, this retrospective study included patients from a large trauma center in Riyadh, SA. PATIENTS AND METHODS A staff nurse utilized a structured checklist to gather information on patients' demographic, physiologic, anatomic, and outcome variables. Basic descriptive statistics by age group ( 14 years) were calculated, and differences were assessed using student t and chi-square tests. In addition, the mechanism of injury and the frequency of missing data were evaluated. RESULTS 10 847 patients from the trauma registry were included. Over 9% of all patients died either before or after being treated at the hospital. Patients who were older than 14 years of age (more likely to be male) sustained traffic-related injuries and died in the hospital as compared to patients who were younger than or equal to years of age. Deceased patients were severely injured as measured by injury severity score and Glasgow Coma Scale (P < .001). Overall, the most frequent type of injury was related to traffic (52.0%), followed by falls (23.4%). Missing values were mostly prevalent in traffic-related variables, such as seatbelt use (70.2%). CONCLUSION This registry is a key step toward addressing the burden of injuries in SA. Improved injury classification using the International Classification of Disease-external cause codes may improve the quality of the registry and allow comparison with other populations. Most importantly, injury prevention in SA requires further investment in data collection and research to improve outcomes.
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Affiliation(s)
- Suliman Alghnam
- Dr. Suliman Alghnam, King Abdullah International Research Center (KAIMRC) Population Health, PO Box 22490 Riyadh 11426 Saudi Arabia, T: 966566639414,
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Odetola FO, Gebremariam A. Paediatric trauma in the USA: patterns of emergency department visits and associated hospital resource use. Int J Inj Contr Saf Promot 2014; 22:260-6. [PMID: 24941303 DOI: 10.1080/17457300.2014.925937] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Trauma is the leading cause of mortality and morbidity among children in the USA. To examine the variation in the epidemiology and patterns of visits to emergency departments (EDs), and test the hypothesis that children evaluated at trauma centre EDs will have higher injury severity and a higher likelihood of hospitalisation versus those evaluated at non-trauma centre EDs, we analysed a national database of all injured children aged 0-20 years evaluated at US EDs in 2009. Childhood injuries are a frequent cause of visits to US EDs, with a national point prevalence of 620 cases per 10,000 children aged 0-20 years. Epidemiology of childhood injuries in the USA is significant for male gender preponderance, significant seasonal and geographical variation, and disproportionately more frequent injury to the extremities than other sites of the body. National hospital resource use was significant, with greater burden borne by trauma centres which disproportionately provided care to the most severely injured children.
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Affiliation(s)
- Folafoluwa O Odetola
- a Department of Pediatrics and Communicable Diseases, Division of Pediatric Critical Care Medicine , University of Michigan Health System , Ann Arbor , MI , USA
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Scott VK, Hashmi ZG, Schneider EB, Hui X, Efron DT, Cornwell EE, Cooper LA, Haider AH. Counting the lives lost: how many black trauma deaths are attributable to disparities? J Surg Res 2013; 184:480-7. [PMID: 23827793 DOI: 10.1016/j.jss.2013.04.080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/23/2013] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The number of black trauma deaths attributable to racial disparities is unknown. The objective of this study was to quantify the excess mortality experienced by black patients given disparities in the risk of mortality. MATERIALS AND METHODS We performed a retrospective analysis of patients aged 16-65 y with blunt and penetrating injuries, who were included in the National Trauma Data Bank from 2007-2010. Generalized linear modeling estimated the relative risk of death for black patients versus white patients, adjusting for known confounders. This analysis determined the difference in the observed number of black trauma deaths at Level I and II centers and the expected number of deaths if the risk of mortality for black patients had been equivalent to that of white patients. RESULTS A total of 1.06 million patients were included. Among patients with blunt and penetrating injuries at Level I trauma centers, white males and females had a relative risk of death of 0.82 (95% confidence interval [CI], 0.80-0.85) and 0.78 (95% CI, 0.74-0.83), respectively, compared with black patients. Similarly, at Level II trauma centers, white males and females had a relative risk of death of 0.84 (95% CI, 0.80-0.88) and 0.82 (95% CI, 0.73-0.91). Overall, of the estimated 41,613 deaths that occurred at Level I and II centers, 2206 (5.3%) were excess deaths among black patients. CONCLUSIONS Over a 4-y period, approximately 5% of trauma center deaths could be attributed to racial disparities in trauma outcomes. These data underscore the need to better understand and intervene against the mechanisms that lead to trauma outcomes disparities.
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Affiliation(s)
- Valerie K Scott
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
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Asemota AO, George BP, Bowman SM, Haider AH, Schneider EB. Causes and Trends in Traumatic Brain Injury for United States Adolescents. J Neurotrauma 2013; 30:67-75. [DOI: 10.1089/neu.2012.2605] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anthony O. Asemota
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Benjamin P. George
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Steven M. Bowman
- Department of Community Health, National University Technology and Health Sciences Center, San Diego, California
| | - Adil H. Haider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric B. Schneider
- Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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Zonfrillo MR, Durbin DR, Winston FK, Zhao H, Stineman MG. Physical disability after injury-related inpatient rehabilitation in children. Pediatrics 2013; 131:e206-13. [PMID: 23248228 PMCID: PMC4528339 DOI: 10.1542/peds.2012-1418] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [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 determine the residual physical disability after inpatient rehabilitation for children 7 to 18 years old with traumatic injuries. METHODS This was a retrospective cohort study of patients aged 7 to 18 years who underwent inpatient rehabilitation for traumatic injuries from 2002 to 2011. Patients were identified from the Uniform Data System for Medical Rehabilitation. Injuries were captured by using standardized Medicare Inpatient Rehabilitation Facility Patient Assessment Instrument codes. Functional outcome was measured with the Functional Independence Measure (FIM) instrument. A validated, categorical grading system of the FIM motor items was used, consisting of clinically relevant levels of physical achievement from grade 1 (need for total assistance) to grade 7 (completely independent for self-care and mobility). RESULTS A total of 13,798 injured children underwent inpatient rehabilitation across 523 facilities during the 10-year period. After a mean 3-week length of stay, functional limitations were reduced, but children still tended to have residual physical disabilities (median admission grade: 1; median discharge grade: 4). Children with spinal cord injuries, either alone or in combination with other injuries, had lower functional grade at discharge, longer lengths of stay, and more comorbidities at discharge than those with traumatic brain injuries, burns, and multiple injuries (P < .0001 for all comparisons). CONCLUSIONS Children had very severe physical disability on admission to inpatient rehabilitation for traumatic injuries, and those with spinal cord injuries had persistent disability at discharge. These traumatic events during critical stages of development may result in a substantial care burden over the child's lifespan.
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Affiliation(s)
- Mark R. Zonfrillo
- Center for Injury Research and Prevention, and,Department of Pediatrics,,Center for Clinical Epidemiology and Biostatistics, and
| | - Dennis R. Durbin
- Center for Injury Research and Prevention, and,Department of Pediatrics,,Center for Clinical Epidemiology and Biostatistics, and
| | - Flaura K. Winston
- Center for Injury Research and Prevention, and,Department of Pediatrics,,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Huaqing Zhao
- Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Margaret G. Stineman
- Center for Clinical Epidemiology and Biostatistics, and,Department of Physical Medicine and Rehabilitation, Perelman School of Medicine, and,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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