Epidemiology of injury and the impact of health disparities

Disparities in Pedestrian and Cyclist Crashes by Social Vulnerability Across South Carolina

BACKGROUND

Little crash equity research has controlled for active transportation rates, examined the Southeastern United States, or used composite sociodemographic metrics. This study analyzed disparities in pedestrian and cyclist crashes and crash severity according to level of social vulnerability (SV) across South Carolina.

METHODS

Data about SV and its 4 dimensions (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation) were compiled for all census tracts (N = 1103) within South Carolina. Data for all crashes involving a pedestrian (n = 10,688) and/or cyclist (n = 4802) from 2011 to 2021 were obtained from the South Carolina Department of Transportation and geocoded to the respective census tract. Total average pedestrian and cyclist crash severity (Equivalent Property Damage Only) were also calculated for each tract. Crash frequency and severity scores were adjusted using the average number of walking and cycling trips in the census tract per year using StreetLight Data. Mixed-model linear regression analyzed the relationships between overall SV and the 4 SV dimensions and 4 crash measures-pedestrian and cyclist frequency and severity. Stratified analyses were conducted for urban and rural tracts.

RESULTS

Overall SV was positively and significantly associated with all 4 crash outcomes in urban areas: pedestrian crashes per trip (B = 0.048, SE = 0.012, P < .001), pedestrian crash severity per trip (B = 9.018, SE = 2.516, P < .001), cyclist crashes per trip (B = 0.093, SE = 0.029, P < .01), and cyclist crash severity per trip (B = 16.370, SE = 5.482, P < .01). In urban areas, greater SV was associated with more severe pedestrian and cyclist crash outcomes.

CONCLUSIONS

Targeted policy and programmatic and infrastructure interventions are needed to improve active transportation safety and public health.

Neighborhood-based Social Determinants of Health are Associated With Decreased Helmet Use in Young Children

PURPOSE

We sought to determine the association between neighborhood-level social determinants of health (SDoH) and protective helmet use for young children involved in bicycle, scooter, and skateboard crashes. We hypothesized that children from disadvantaged communities would be less likely to be wearing helmets at the time of their crash.

METHODS

A retrospective cohort study was performed of all children ≤10 years old who presented after bicycle, scooter, and skateboard crashes to a single Level 1 Pediatric Trauma Center (7/1/2017-6/30/2021). Geocoding linked patient addresses to state-Area Deprivation Index (ADI) and Social Vulnerability Index (SVI). Multivariable logistic regression modeling investigated associations between neighborhood-level SDoH and helmet use, controlling for age, sex, and racialization. ADI and SVI were scaled to present decile change (0 = least disadvantaged, 10 = most disadvantaged).

RESULTS

220 children were in bicycle, scooter, and skateboard crashes, 56 % of whom were not wearing helmets. The median age was 7.6 years, 71 % were male, 52 % were on public insurance, and 63 % had minoritized racialization. Neighborhood-level SDoH indices were significantly associated with helmet use, with a 27 % (95 % CI 1.10-1.39, p < 0.001) increase in the odds of no helmet use for every decile increase in overall SVI, and a 23 % (95 % CI 1.12-1.44, p < 0.001) increase in the odds of no helmet use every decile increase in ADI.

CONCLUSIONS

Helmet use in young children was found to be closely associated with community structural factors. Neighborhood-level SDoH indices may be an effective tool for identifying at-risk communities for the development of injury prevention interventions.

LEVEL OF EVIDENCE

Prognosis Study, Level II.

Exploring the link among injury severity, white matter connectivity and psychosocial outcomes in pediatric TBI: a probabilistic tractography approach

AIM

We examined associations among injury severity, white matter structural connectivity within functionally defined brain networks and psychosocial/adaptive outcomes in children with traumatic brain injury (TBI).

METHOD

Participants included 58 youths (39 male) with complicated-mild TBI (cmTBI; n = 12, age =  12.6 ± 2.0), moderate/severe TBI (msTBI; n =  16, age =  11.4 ± 2.9) and a comparison group with orthopedic injury (OI; n =  24, age =  11.7 ± 2.1), at least 1 year post-injury. Participants underwent diffusion tensor imaging and parents rated children's behavioral and adaptive function on the CBCL and ABAS-3, respectively. Probabilistic tractography quantified streamline density. Group differences were analyzed for structural connectivity and behavioral outcomes.

RESULTS

Groups differed in structural connectivity within regions of the default mode and central executive networks (ps < .05, FDR corrected). The msTBI group displayed decreased connectivity relative to cmTBI and OI, whereas the cmTBI group displayed increased connectivity relative to msTBI and OI. Similar patterns emerged in several behavioral domains. Ordinary least squares path analyses showed that structural connectivity mediated the relationship between injury severity and multiple parent-reported outcomes for msTBI.

INTERPRETATION

White matter structural connectivity may explain unique variance in long-term psychosocial and adaptive outcome in children with TBI, particularly in cases of moderate-to-severe injury.

Neighborhood child opportunity is associated with hospital length of stay following pediatric burn injury

INTRODUCTION

Pediatric burns are associated with socioeconomic disadvantage and lead to significant morbidity. The Child Opportunity Index (COI) is a well-validated measure of neighborhood characteristics associated with healthy child development. We sought to evaluate the relationship between COI and outcomes of burn injuries in children.

METHODS

We performed a single-institution retrospective review of pediatric (<16 years) burn admissions between 2015 and 2019. Based on United States residential zip codes, patients were stratified into national COI quintiles. We performed a multivariate Poisson regression analysis to determine the association between COI and increased length of stay.

RESULTS

2095 pediatric burn admissions occurred over the study period. Most children admitted were from very low (n = 644, 33.2 %) and low (n = 566, 29.2 %) COI neighborhoods. The proportion of non-Hispanic Black patients was significantly higher in neighborhoods with very low (44.5 %) compared to others (low:28.8 % vs. moderate:11.9 % vs. high:10.5 % vs. very high:4.3 %) (p < 0.01). Hospital length of stay was significantly longer in patients from very low COI neighborhoods (3.6 ± 4.1 vs. 3.2 ± 4.9 vs. 3.3 ± 4.8 vs. 2.8 ± 3.5 vs. 3.2 ± 8.1) (p = 0.02). On multivariate regression analysis, living in very high COI neighborhoods was associated with significantly decreased hospital length of stay (IRR: 0.51; 95 % CI: 0.45-0.56).

CONCLUSION

Children from neighborhoods with significant socioeconomic disadvantage, as measured by the Child Opportunity Index, had a significantly higher incidence of burn injuries resulting in hospital admissions and longer hospital length of stay. Public health interventions focused on neighborhood-level drivers of childhood development are needed to decrease the incidence and reduce hospital costs in pediatric burns.

TYPE OF STUDY

Retrospective study LEVEL OF EVIDENCE: Level III.

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life.

METHODS

We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors.

RESULTS

A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively.

CONCLUSIONS

In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.

Childhood Physical Health and Attention Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis of Modifiable Factors

Although neurobiologic and genetic factors figure prominently in the development of attention deficit/hyperactivity disorder (ADHD), adverse physical health experiences and conditions encountered during childhood may also play a role. Poor health is known to impact the developing brain with potential lifelong implications for behavioral issues. In attempt to better understand the relationship between childhood physical health and the onset and presence of ADHD symptoms, we summarized international peer-reviewed articles documenting relationships between a select group of childhood diseases or health events (e.g., illnesses, injuries, syndromes) and subsequent ADHD outcomes among children ages 0-17 years. Drawing on a larger two-phase systematic review, 57 longitudinal or retrospective observational studies (1978-2021) of childhood allergies, asthma, eczema, head injury, infection, or sleep problems and later ADHD diagnosis or symptomatology were identified and subjected to meta-analysis. Significant associations were documented between childhood head injuries, infections, and sleep problems with both dichotomous and continuous measures of ADHD, and between allergies with dichotomous measures of ADHD. We did not observe significant associations between asthma or eczema with ADHD outcomes. Heterogeneity detected for multiple associations, primarily among continuously measured outcomes, underscores the potential value of future subgroup analyses and individual studies. Collectively, these findings shed light on the importance of physical health in understanding childhood ADHD. Possible etiologic links between physical health factors and ADHD are discussed, as are implications for prevention efforts by providers, systems, and communities.

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review

OBJECTIVE

To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps.

BACKGROUND

Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care.

METHODS

We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II."

RESULTS

We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning.

CONCLUSIONS

We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Regional Cortical Thickness Correlates of Intellectual Abilities Differ in Children With Traumatic Brain Injury Versus Those With Orthopedic Injury in the Chronic Post-Injury Phase

A decline in intellectual functioning (intelligence quotient [IQ]) is often observed following more severe forms of traumatic brain injury (TBI) and is a useful index for long-term outcome. Identifying brain correlates of IQ can serve to inform developmental trajectories of behavior in this population. Using magnetic resonance imaging (MRI), we examined the relationship between intellectual abilities and patterns of cortical thickness in children with a history of TBI or with orthopedic injury (OI) in the chronic phase of injury recovery. Participants were 47 children with OI and 58 children with TBI, with TBI severity ranging from complicated-mild to severe. Ages ranged from 8 to 14 years old, with an average age of 10.47 years, and an injury-to-test range of ∼1-5 years. The groups did not differ in age or sex. The intellectual ability estimate (full-scale [FS]IQ-2) was derived from a two-form (Vocabulary and Matrix Reasoning subtests) Wechsler Abbreviated Scale of Intelligence (WASI). MRI data were processed using the FreeSurfer toolkit and harmonized across data collection sites using neuroComBat procedures, while holding demographic features (i.e., sex, socioeconomic status [SES]), TBI status, and FSIQ-2 constant. Separate general linear models per group (TBI and OI) and a single interaction model with all participants were conducted with all significant results withstanding correction for multiple comparisons via permutation testing. Intellectual ability was higher (p < 0.001) in the OI group (FSIQ-2 = 110.81) than in the TBI group (FSIQ-2 = 99.81). In children with OI, bi-hemispheric regions, including the right pre-central gyrus and precuneus and bilateral inferior temporal and left occipital areas were related to IQ, such that higher IQ was associated with thicker cortex in these regions. In contrast, only cortical thickness in the right pre-central gyrus and bilateral cuneus positively related to IQ in children with TBI. Significant interaction effects were found in the bilateral temporal, parietal, and occipital lobes and left frontal regions, indicating that the relationship between IQ and cortical thickness differed between groups in these regions. Changes in cortical associations with IQ after TBI may reflect direct injury effects and/or adaptation in cortical structure and intellectual functioning, particularly in the bilateral posterior parietal and inferior temporal regions. This suggests that the substrates of intellectual ability are particularly susceptible to acquired injury in the integrative association cortex. Longitudinal work is needed to account for normal developmental changes and to investigate how cortical thickness and intellectual functioning and their association change over time following TBI. Improved understanding of how TBI-related cortical thickness alterations relate to cognitive outcome could lead to improved predictions of outcome following brain injury.

Race, area deprivation index, and access to surgical burn care in a pediatric population in North Carolina

BACKGROUND

Burns represent a leading cause of morbidity and mortality for children. This study explores the intersecting effects of social deprivation and race in pediatric burn patients.

METHODS

We performed a retrospective review of all pediatric patients (<18 years old) admitted to a tertiary burn center in North Carolina from 2009 to 2019. We used bivariate analysis to compare patients based on reported race, comparing African Americans (AA) to all others. Modified Poisson regression was used to model the probability of undergoing autologous skin grafting based on AA race.

RESULTS

Of 4227 children admitted, AA children were disproportionally represented, comprising 33.7% of patients versus a state population of 22.3%. AA patients had larger %TBSA with a median of 3% (IQR 1-6) compared to 2% (IQR 1-5, p < 0.001) and longer median length of stay at 5.8 days (SD 13.6) versus 4.9 days (SD 13.8). AA patients were more likely to have autologous skin grafting compared to other races, with an adjusted RR of 1.49 (95% CI 1.22-1.83) when controlling for Area Deprivation Index (ADI) national rank, age, %TBSA, and burn type.

CONCLUSIONS

AA children were disproportionately represented and had larger burns, even when controlling for ADI. They had longer hospital stays and were more likely to have autologous skin grafting, even accounting for burn size and type. The intersection between social deprivation and race creates a unique risk for AA patients. Further investigation into this phenomenon and factors underlying surgical intervention selection are indicated to inform best treatment practices and future preventative strategies.

Post-Burn Psychosocial Outcomes in Pediatric Minority Patients in the United States: An Observational Cohort Burn Model System Study

Racial and ethnic minority burn patients face barriers to longitudinal psychosocial support after injury. Studies utilizing the Burn Model System (BMS) National Database report adult minority patients experience worse psychosocial outcomes in domains such as body image during burn recovery. No study to date has investigated disparities in psychosocial outcomes by racial or ethnic category in the pediatric population using the BMS database. This observational cohort study addresses this gap and examines seven psychosocial outcomes (levels of anger, sadness, depression, anxiety, fatigue, peer relationships, and pain) in pediatric burn patients. The BMS database is a national collection of burn patient outcomes from four centers in the United States. BMS outcomes collected were analyzed using multi-level, linear mixed effects regression modeling to examine associations between race/ethnicity and outcomes at discharge after index hospitalization, and 6- and 12-months post-injury. A total of 275 pediatric patients were included, of which 199 (72.3%) were Hispanic. After burn injury, of which the total body surface area was significantly associated with racial/ethnicity category (p < 0.01), minority patients more often reported higher levels of sadness, fatigue, and pain interference and lower levels of peer relationships compared to Non-Hispanic, White patients, although no significant differences existed. Black patients reported significantly increased sadness at six months (β = 9.31, p = 0.02) compared to discharge. Following burn injury, adult minority patients report significantly worse psychosocial outcomes than non-minority patients. However, these differences are less profound in pediatric populations. Further investigation is needed to understand why this change happens as individuals become adults.

Sociodemographic factors associated with tracheostomy and mortality in bronchopulmonary dysplasia

OBJECTIVES

We sought to investigate how race, ethnicity, and socioeconomic status relate to tracheostomy insertion and post-tracheostomy mortality among infants with bronchopulmonary dysplasia (BPD).

METHODS

The Vizient Clinical Database/Resource Manager was queried to identify infants born ≤32 weeks with BPD admitted to US hospitals from January 2012 to December 2020. Markers of socioeconomic status were linked to patient records from the Agency for Healthcare Research and Quality's Social Determinants of Health Database. Regression models were used to assess trends in annual tracheostomy insertion rate and odds of tracheostomy insertion and post-tracheostomy mortality, adjusting for sociodemographic and clinical factors.

RESULTS

There were 40,021 ex-premature infants included in the study, 1614 (4.0%) of whom received a tracheostomy. Tracheostomy insertion increased from 2012 to 2017 (3.1%-4.1%), but decreased from 2018 to 2020 (3.3%-1.6%). Non-Hispanic Black infants demonstrated a 25% higher odds (aOR 1.25, 1.09-1.43) and Hispanic infants demonstrated a 20% lower odds (aOR 0.80, 0.65-0.96) of tracheostomy insertion compared with non-Hispanic White infants. Patients receiving public insurance had increased odds of tracheostomy insertion (aOR 1.15, 1.03-1.30), but there was no relation between other metrics of socioeconomic status and tracheostomy insertion within our cohort. In-hospital mortality among the tracheostomy-dependent was 14.1% and was not associated with sociodemographic factors.

CONCLUSIONS

Disparities in tracheostomy insertion are not accounted for by differences in socioeconomic status or the presence of additional neonatal morbidities. Post-tracheostomy mortality does not demonstrate the same relationships. Further investigation is needed to explore the source and potential mitigators of the identified disparities.

Using the Social Vulnerability Index to Examine Disparities in Surgical Pediatric Trauma Patients

INTRODUCTION

The Social Vulnerability Index (SVI) is a composite measure geocoded at the census tract level that has the potential to identify target populations at risk for postoperative surgical morbidity. We applied the SVI to examine demographics and disparities in surgical outcomes in pediatric trauma patients.

METHODS

Surgical pediatric trauma patients (≤18-year-old) at our institution from 2010 to 2020 were included. Patients were geocoded to identify their census tract of residence and estimated SVI and were stratified into high (≥70th percentile) and low (<70th percentile) SVI groups. Demographics, clinical data, and outcomes were compared using Kruskal-Wallis and Fisher's exact tests.

RESULTS

Of 355 patients included, 21.4% had high SVI percentiles while 78.6% had low SVI percentiles. Patients with high SVI were more likely to have government insurance (73.7% versus 37.2%, P < 0.001), be of minority race (49.8% versus 19.1%, P < 0.001), present with penetrating injuries (32.9% versus 19.7%, P = 0.007), and develop surgical site infections (3.9% versus 0.4%, P = 0.03) compared to the low SVI group.

CONCLUSIONS

The SVI has the potential to examine health care disparities in pediatric trauma patients and identify discrete at-risk target populations for preventative resources allocation and intervention. Future studies are necessary to determine the utility of this tool in additional pediatric cohorts.

A 10-Year National Analysis of Pediatric Elbow Fractures

Elbow fractures comprise 15% of all fractures in children. Our study identifies risk factors and consumer products that contribute to pediatric elbow fractures. The National Electronic Injury Surveillance System was used to collect demographic and consumer product information between 2010 and 2019 for patients younger than 17 years who presented to the emergency department with elbow fractures. Of the 458,433 elbow fractures, the average age of the patients was 7.4 ± 4.1 years and 55.6% were male children. The most common consumer product was sports and recreation equipment, followed by home furnishings. Male patients (P < .0001) and patients 8 years and older (79.2% vs 51.1%, P < .0001) experienced significantly greater rates of injury with sports and recreation equipment. This study evaluates the products associated with pediatric elbow fractures and highlights the importance of safe sports and recreation equipment use and the role of parental counseling in preventing falls from furniture.

Injury-Related Pediatric Emergency Department Visits in the First Year of COVID-19

OBJECTIVES

To describe the epidemiology of pediatric injury-related visits to children's hospital emergency departments (EDs) in the United States during early and later periods of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

METHODS

We conducted a cross-sectional study using the Pediatric Health Information System, an administrative database to identify injury-related ED visits at 41 United States children's hospitals during the SARS-CoV-2 pandemic period (March 15, 2020 to March 14, 2021) and a 3 year comparator period (March 15-March 14, 2017-2020). For these 2 periods, we compared patient characteristics, injury type and severity, primary discharge diagnoses, and disposition, stratified by early (March 15, 2020 to June 30, 2020), middle (July 1, 2020 to October 31, 2020), and late (November 1, 2020 to March 14, 2021) pandemic periods.

RESULTS

Overall, ED injury-related visits decreased by 26.6% during the first year of the SARS-CoV-2 pandemic, with the largest decline observed in minor injuries. ED injury-related visits resulting in serious-critical injuries increased across the pandemic (15.9% early, 4.9% middle, 20.6% late). Injury patterns with the sharpest relative declines included superficial injuries (41.7% early) and sprains/strains (62.4% early). Mechanisms of injury with the greatest relative increases included (1) firearms (22.9% early; 42.8% middle; 37% late), (2) pedal cyclists (60.4%; 24.9%; 32.2%), (3) other transportation (20.8%; 25.3%; 17.9%), and (4) suffocation/asphyxiation (21.4%; 20.2%; 28.4%) and injuries because of suicide intent (-16.2%, 19.9%, 21.8%).

CONCLUSIONS

Pediatric injury-related ED visits declined in general. However, there was a relative increase in injuries with the highest severity, which warrants further investigation.

Social determinants of participant recruitment and retention in a prospective cohort study of pediatric mild traumatic brain injury

Background

Prior studies have shown poor recruitment and retention of minoritized groups in clinical trials.

Objective

To examine several social determinants as predictors of consent to participate and retention as part of a prospective, longitudinal cohort study of children 8–16 with either mild traumatic brain injury (mild TBI) or orthopedic injury (OI).

Methods

Children and families were recruited during acute visits to emergency departments (ED) in two large children's hospitals in the midwestern United States for a prospective, longitudinal cohort study of children 8–16 with either mild TBI or OI.

Results

A total of 588 (mild TBI = 307; OI = 281) eligible children were approached in the ED and 315 (mild TBI = 195; OI = 120) were consented. Children who consented did not differ significantly from those who did not consent in sex or age. Consent rates were higher among Black (60.9%) and multi-racial (76.3%) children than white (45.3%) children. Among the 315 children who consented, 217 returned for a post-acute assessment (mild TBI = 143; OI = 74), a retention rate of 68.9%. Participants who were multi-racial (96.6%) or white (79.8%) were more likely to return for the post-acute visit than those who were Black (54.3%).

Conclusions

Racial differences exist in both recruitment and retention of participants in a prospective, longitudinal cohort of children with mild TBI or OI. Further work is needed to understand these differences to ensure equitable participation of minoritized groups in brain injury research.

Racial Disparities in Postoperative Outcomes Following Operative Management of Pediatric Developmental Dysplasia of the Hip

BACKGROUND

Developmental dysplasia of the hip in pediatric patients can be managed conservatively or operatively. Understanding patient risk factors is important to optimize outcomes following surgical treatment of developmental dysplasia of the hip. Racial disparities in procedural outcomes have been studied, however, there is scarce literature on an association between race and complications following pediatric orthopaedic surgery. Our study aimed to determine the association between pediatric patients' race and outcomes following operative management of hip dysplasia by investigating 30-day postoperative complications and length of hospital stay.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was utilized from the years 2012 to 2019 to identify all pediatric patients undergoing surgical treatment for hip dysplasia. Patients were stratified into 2 groups: patients who were White and patients from underrepresented minority (URM) groups. URM groups included those who were Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Differences in patient demographics, comorbidities, and postoperative outcomes were compared between the 2 cohorts using bivariate and multivariate analyses.

RESULTS

Of the 9159 pediatric patients who underwent surgical treatment for hip dysplasia between 2012 and 2019, 6057 patients (66.1%) were White and 3102 (33.9%) were from URM groups. In the bivariate analysis, compared with White patients, patients from URM groups were more likely to experience deep wound dehiscence, pneumonia, unplanned reintubation, cardiac arrest, and extended length of hospital stay. Following multivariate analysis, patients from URM groups had an increased risk of unplanned reintubation (odds ratio: 3.583; P=0.018).

CONCLUSIONS

Understanding which patient factors impact surgical outcomes allows health care teams to be more aware of at-risk patient groups. Our study found that pediatric patients from URM groups who underwent surgery for correction of hip dysplasia had greater odds of unplanned reintubation when compared with patients who were White. Further research should investigate the relationship between multiple variables including race, low socioeconomic status, and language barriers on surgical outcomes following pediatric orthopaedic procedures.

LEVEL OF EVIDENCE

Level III-retrospective cohort analysis.

Trends and Disparities in Inpatient Rehabilitation of Adolescents: The Effect of Demographics, Injury Characteristics, and Facility Type

BACKGROUND

Intensive rehabilitation of adolescents occurs in general and pediatric inpatient rehabilitation facilities (IRFs), but differences in admission and outcomes by facility type have not been thoroughly investigated, particularly among persons with spinal cord injury (SCI).

OBJECTIVES

To investigate factors related to admission to pediatric or adult IRFs among adolescents and compare the rehabilitation outcomes between facility types.

METHODS

Using a single-center retrospective cohort study design, demographic information, medical data, and rehabilitation outcomes were obtained by chart review of patients aged 15 to 18 years who received a rehabilitation medicine consultation at an urban level 1 trauma center between 2017 and 2019 (N = 96). Analysis was performed using R statistical software.

RESULTS

SCI was the second most common diagnosis (21% of patients) and accounted for 36% of inpatient rehabilitation admissions. SCI patients were more likely to undergo rehabilitation at the level 1 trauma versus pediatric facility (relative risk [RR] = 2.43; 95% confidence interval [CI] = 1.08-5.44) compared to traumatic brain injury patients. Admission to trauma versus pediatric IRF was also associated with Black compared to White race (RR = 2.5; CI = 1.12-5.56), violence compared to other etiologies of injury (RR = 2.0; CI = 1.10-3.77), and Medicaid compared to private insurance (RR = 2.15; CI = 1.01-4.59). Admission to pediatric IRF was associated with longer length of stay than admission to adult IRF when adjusted for diagnosis (30.86 ± 21.82 vs. 24.33 ± 18.17 days; p = .046), but Functional Independence Measures did not differ.

CONCLUSION

Adolescents with SCI and those experiencing systemic disadvantages, including racism and poverty, were more likely to be admitted to trauma compared to pediatric IRF.

Association of Race With Postoperative Mortality Following Major Abdominopelvic Trauma in Children

BACKGROUND

The leading cause of mortality among children is trauma. Race and ethnicity are critical determinants of pediatric postsurgical outcomes, with minority children generally experiencing higher rates of postoperative morbidity and mortality than White children. This pattern of poorer outcomes for racial and/or ethnic minority children has also been demonstrated in children with head and limb traumas. While injuries to the abdomen and pelvis are not as common, they can be life-threatening. Racial and/or ethnic differences in outcomes of pediatric abdominopelvic operative traumas have not been examined. Our objective was to determine whether disparities exist in postoperative mortality among children with major abdominopelvic trauma.

MATERIALS AND METHODS

We performed a retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for 2003, 2006, 2009, and 2012. Patients were included if they were < 18 years, sustained a major abdominopelvic injury, and underwent subsequent surgical intervention. Our primary outcome was inpatient mortality, comparing children of different race and/or ethnicity.

RESULTS

We identified a weighted cohort of 13,955 children, of whom 6765 (48.5%) were White, 3614 (25.9%) Black, and 2647 (19.0%) Hispanic. After adjusting for covariates, Black children were 94% more likely to die than their White peers (3.3% versus 1.6%, adjusted-RR:1.94, 95%CI: 1.33-2.82, P = 0.001). Hispanic children (adjusted-RR:1.99, 95%CI: 1.36-2.91, P < 0.001) and those of other race and/or ethnicity (adjusted-RR: 2.02, 95%CI:1.20-3.40, P = 0.008) were also more likely to die compared to their White peers.

CONCLUSIONS

Black and Hispanic children who require operative intervention following major abdominopelvic trauma have a higher risk of postoperative mortality compared with White children.

Ethical challenges with decisions to withhold or withdraw resuscitation in pediatric surgery

Providers often dispute the ethical equivalence of withholding and withdrawing care, despite theoretical frameworks that support equivalency. We highlight two cases, one where providers express concern with initiation of aggressive resuscitation and another where providers experience emotional distress from the decision to cease resuscitation. Both cases illustrate how the ethical challenges encountered can result in high levels of provider distress. Mitigation of this moral distress by team members will require an improved understanding of available evidence in the literature and active discussion by debriefing after a child dies. Medical staff and national organizations can help recognize that these patient events contribute to provider burnout and facilitate the design and support of programs to increase provider resiliency.

Health informatics and health equity: improving our reach and impact

Health informatics studies the use of information technology to improve human health. As informaticists, we seek to reduce the gaps between current healthcare practices and our societal goals for better health and healthcare quality, safety, or cost. It is time to recognize health equity as one of these societal goals-a point underscored by this Journal of the American Medical Informatics Association Special Focus Issue, "Health Informatics and Health Equity: Improving our Reach and Impact." This Special Issue highlights health informatics research that focuses on marginalized and underserved groups, health disparities, and health equity. In particular, this Special Issue intentionally showcases high-quality research and professional experiences that encompass a broad range of subdisciplines, methods, marginalized populations, and approaches to disparities. Building on this variety of submissions and other recent developments, we highlight contents of the Special Issue and offer an assessment of the state of research at the intersection of health informatics and health equity.

The mentalizing network and theory of mind mediate adjustment after childhood traumatic brain injury

Childhood traumatic brain injury (TBI) affects over 600 000 children per year in the United States. Following TBI, children are vulnerable to deficits in psychosocial adjustment and neurocognition, including social cognition, which persist long-term. They are also susceptible to direct and secondary damage to related brain networks. In this study, we examine whether brain morphometry of the mentalizing network (MN) and theory of mind (ToM; one component of social cognition) mediates the effects of TBI on adjustment. Children with severe TBI (n = 15, M_age = 10.32), complicated mild/moderate TBI (n = 30, M_age = 10.81) and orthopedic injury (OI; n = 42, M_age = 10.65) completed measures of ToM and executive function and underwent MRI; parents rated children’s psychosocial adjustment. Children with severe TBI demonstrated reduced right-hemisphere MN volume, and poorer ToM, vs children with OI. Ordinary least-squares path analysis indicated that right-hemisphere MN volume and ToM mediated the association between severe TBI and adjustment. Parallel analyses substituting the central executive network and executive function were not significant, suggesting some model specificity. Children at greatest risk of poor adjustment after TBI could be identified based in part on neuroimaging of social brain networks and assessment of social cognition and thereby more effectively allocate limited intervention resources.

Sociogenomic Approach to Wound Care: A New Patient-Centered Paradigm

Psychoneuroendocrinology studies provided first insight into social determinants of wound healing. Social stressors impede wound healing. In 2005, we first reported that the transcriptome of wound-site neutrophil is highly responsive to psychological stress in young men. Bioinformatics processing of transcriptome-wide data from neutrophils provided first insight into social transduction pathways relevant to wound healing. In 2010, Idaghdour et al. presented striking evidence demonstrating that genetic factors are responsible for only 5% of the variation in genomic expression. In contrast, the living environment of the individual, urban or rural, was responsible for as much as 50% of such variation. Genetic and environmental factors acted in a largely additive manner. This observation may be credited as the foundation stone of human social genomics. The environment of a patient, including social factors, influences gene expression relevant to wound healing. The nonhealing wound itself and its worsening outcome, including pain, are likely to cause stress. Conversely, positive social interactions may circumvent barriers to wound healing. Thus, interventions directed at the social environment of a wound care patient are likely to help manage wound chronicity. The genomic and related Big Data technology platforms have vastly improved during the past 5 years during which these technologies have also become widely accessible and affordable. Thus, this is the right time to revisit the choice of technologies for the study of social genomics of wound healing. Against the backdrop of our current understanding of the mechanisms of wound healing, such precision approach is likely to transform wound care and its outcomes making it patient-centered and, therefore, more effective.

Variations in Mechanisms of Injury for Children with Concussion

OBJECTIVES

To assess the distribution of injury mechanisms and activities among children with concussions in a large pediatric healthcare system.

STUDY DESIGN

All patients, age 0-17 years, who had at least 1 clinical encounter with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis of concussion in the Children's Hospital of Philadelphia's electronic health record system from July 1, 2012 to June 30, 2014, were selected (N = 8233) and their initial concussion-related visit identified. Approximately, 20% of the patients (n = 1625) were randomly selected for manual record review to examine injury mechanisms and activities.

RESULTS

Overall, 70% of concussions were sports related; however, this proportion varied by age. Only 18% of concussions sustained by children aged 0-4 were sports related, compared with greater proportions for older children (67% for age 5-11, 77% for age 12-14, and 73% for age 15-17). When the concussion was not sports related, the primary mechanisms of injury were struck by an object (30%) and falls (30%).

CONCLUSIONS

Sports-related injuries in children older than 6 years of age contributed to the majority of concussions in this cohort; however, it is important to note that approximately one-third of concussions were from non-sports-related activities. Although there is increased participation in community and organized sports activities among children, a focus on prevention efforts in other activities where concussions occur is needed.

A National Study of the Effect of Race, Socioeconomic Status, and Gender on Burn Outcomes

Age, burn size, and inhalation injury are the major contributing variables related to burn mortality. While the female gender has been linked to higher mortality, the impact of socioeconomic status has not been well studied. The interplay between these three factors is also unknown. This study sought to clarify the effects of these variables on outcomes in a national sample of patients with burns. A retrospective review of 172,640 patient records of the National Burn Repository (version 8, 2002-2011) data was conducted. Of those records, 36,960 (21.4%) patient entries were excluded for duplicate entries, follow-up visits, readmissions, nonburn injuries, skin diseases, and incompleteness (missing date of admission, date of discharge, race, or TBSA of burn or TBSA). Univariate and multivariate analyses were performed to compare outcomes by race (Caucasian, African-American, and other minority groups). P < .05 was considered significant. The study group included 135,680 patients and was predominately Caucasian (59.0% Caucasian, 19.0% African-American, and 22.0% other minority groups). The African-American race had more females, operations, longer length of stay, ventilator days, septicemia (all P < .001), and urinary tract infections (UTIs, P < .01). Caucasians had the largest burns (9.27 ± 13.22, P <.001) and were more likely to be older, to be intubated, and to have longer intensive care unit stays and higher mortality (all P < .001). Other non-African-American minorities (other minority group) had the second largest burn sizes, most uninsured members, and lowest mortality (P < .001). On multivariate analysis, mortality was related to African-American race, female gender, TBSA, full-thickness burn injury, inhalation injury, uninsured status, and burn mechanism. African-Americans were 50% more likely to have complications (P < .001), 30% more likely to have UTIs (P = .002), and 41% more likely to get septicemia (P < .001). Other racial minority groups had more acute respiratory distress syndrome, pneumonias, septicemia, UTIs, length of stay, and hospital charges when compared with Caucasian patients. Socioeconomic status was related to mortality but inconsistently related to other outcomes. Race appears to play a significant role in burn injury outcomes. Minority groups, especially African-Americans, have a higher risk of morbidity and mortality compared with Caucasian patients with burns. Socioeconomic status and gender also play a significant role in burn outcomes. Future studies should focus on delineating the reasons for this disparity.

Prevalence and ethnic/racial disparities in the distribution of pediatric injuries in South Florida: implications for the development of community prevention programs

BACKGROUND

The state of Florida continues to report significant gender, ethnic and racial disparities in trauma incidence, access to care and outcomes in the adult population. Our objective was to assess pediatric injury profiles and ethnic/racial disparities of specific injuries in a Regional Trauma Center (TC) in South Florida.

METHODS

Retrospective data from November 2011 to December 2015 were obtained from the Level 2 TC registry for children ≤21 years old. Demographic, injury pattern, geographic area, injury scores and treatment data were analyzed.

RESULTS

One thousand six hundred ten patients, ages 0-21 years were cared for at the TC from 2011 to 2015.73% were males. Mean age = 15.7 years. Mortality was 2.3%. Using zip code data and using geographic mapping, we identified two main clusters where injuries were occurring. A multinomial regression analysis demonstrated that Hispanics had higher risks of falls (RR 10.4, 95% CI 2.7-29), motorcycle accidents (RR 3.7, 95% CI 1.7-8.2) and motor vehicle accidents (RR 6.4, 95% CI 3.6-11.4). Black/African American children had higher risks of gunshot wounds and resultant mortality (p < 0.01).

CONCLUSION

There were racial, ethnic and gender disparities in the patterns of injury and outcomes among the youth attended at our TC. Geographic mapping allowed us the identification of the zones in South Florida where injuries were occurring. Understanding the differences and using geographic mapping to identify regions of higher prevalence will complement planning for prevention programs.

Rejection Sensitivity as a Moderator of Psychosocial Outcomes Following Pediatric Traumatic Brain Injury

OBJECTIVES

The current study examines whether psychosocial outcomes following pediatric traumatic brain injury (TBI) vary as a function of children's rejection sensitivity (RS), defined as their disposition to be hypersensitive to cues of rejection from peers.

METHODS

Children ages 8-13 with a history of severe TBI (STBI, n=16), complicated mild/moderate TBI (n=35), or orthopedic injury (OI, n=49) completed measures assessing self-esteem and RS on average 3.28 years post-injury (SD=1.33, range=1.25-6.34). Parents reported on their child's emotional and behavioral functioning and social participation.

RESULTS

Regression analyses found moderation of group differences by RS for three outcomes: social participation, self-perceptions of social acceptance, and externalizing behavior problems. Conditional effects at varying levels of RS indicated that externalizing problems and social participation were significantly worse for children with STBI at high levels of RS, compared to children with OI. Social participation for the STBI group remained significantly lower than the OI group at mean levels of RS, but not at low levels of RS. At high levels of RS, self-perceptions of social acceptance were lower for children with moderate TBI compared to OI, but group differences were not significant at mean or low levels of RS. No evidence of moderation was found for global self-worth, self-perceptions of physical appearance or athletic ability, or internalizing problems.

CONCLUSIONS

The findings highlight the salient nature of social outcomes in the context of varying levels of RS. These findings may have implications for the design of interventions to improve social outcomes following TBI. (JINS, 2017, 23, 451-459).

Pediatric Mild Traumatic Brain Injury and Population Health: An Introduction for Nursing Care Providers

Despite increasing injury prevalence of traumatic brain injury (TBI) in children, most injuries in children are mild in severity. Even mild injuries can result in long-term or chronic effects not apparent until the child ages, resulting in increased economic burden and overall lifetime costs related to injury. Early recognition of TBI is essential for ongoing evaluation and management of acute symptoms and reduction of chronic health effects. Providing early interventions to manage acute and postconcussive symptoms and reducing health disparities in children with mild TBI can minimize adverse events that impact health-related quality of life for the injured child and their family and increase overall population health.

The Impact of Payer Source on Trauma Outcomes in a Pediatric Population

OBJECTIVES

Determine if there were differences in conclusions drawn regarding disparities in trauma outcomes based on literature-derived payer source definitions in a pediatric population.

PATIENTS AND METHODS

Retrospective registry review of admitted pediatric trauma patients (≤17 years of age) at a level II pediatric trauma facility. Eligible patients were categorized into 3 payer source definitions: definition 1: commercially insured, Medicaid, uninsured; definition 2: insured, uninsured; definition 3: commercially insured, underinsured. Logistic regression was used to determine the influence of payer source on outcomes.

RESULTS

Payer source was not significant in definition 1, 2, or 3 for intensive care unit length of stay (LOS), hospital LOS, medical consults, or mortality. For hospital disposition, payer source was significant in definition 1, the uninsured were 90% less likely than commercially insured to be discharged to continued care. In definition 2, the uninsured were 88% less likely than insured to be discharged to continued care. In definition 3, the underinsured were 57% less likely than commercially insured to be discharged to continued care.

CONCLUSIONS

Differences between the literature-derived definitions were not observed and therefore conclusions drawn did not differ across definitions. The investigation demonstrated payer source was not associated with in-hospital outcomes (intensive care unit LOS, hospital LOS, medical consults, and mortality), but was with posthospital outcomes. Findings warrant future examinations on the categorization of payer source in pediatric patients and hospital disposition to gain a greater understanding of disparities related to payer source in pediatric trauma, specifically in terms of posthospital care.

Racial and Ethnic Differences in Injury Prevention Behaviors Among Caregivers of Infants

INTRODUCTION

African American and Latino children experience higher rates of traumatic injury and mortality, but the extent to which parents of different races and ethnicities disparately enact injury prevention behaviors has not been fully characterized. The objective of this study is to evaluate the association between caregiver race/ethnicity and adherence to injury prevention recommendations.

METHODS

This was a cross-sectional analysis of caregiver-reported baseline data from the Greenlight study, a cluster-randomized pediatric obesity prevention trial. Data were collected between 2010 and 2012 in four academic pediatric practices and analyzed in 2015. Non-adherence to injury prevention recommendations was based on five domains: car seat safety, sleeping safety, fire safety, hot water safety, and fall prevention.

RESULTS

Among 864 caregiver-infant pairs (17.7% white, non-Hispanic; 49.9% Hispanic; 27.7% black, non-Hispanic; 4.7 % other, non-Hispanic), mean number of non-adherent injury prevention behaviors was 1.8 (SD=0.9). In adjusted regression, Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.1, 95% CI=1.2, 3.8), and lower odds of non-adherence with fall prevention (AOR=0.4, 95% CI=0.3, 0.7) compared with whites. Black, non-Hispanic caregivers had higher odds of non-adherence to car seat safety (AOR=2.4, 95% CI=1.3, 4.4) and sleeping safety (AOR=2.1, 95% CI=1.3, 3.2), but lower odds of fall prevention non-adherence (AOR=0.5, 95% CI=0.3, 0.8) compared with whites.

CONCLUSIONS

A high prevalence of non-adherence to recommended injury prevention behaviors is common across racial/ethnic categories for caregivers of infants among a diverse sample of families from low-SES backgrounds.

Outpatient Rehabilitation for Medicaid-Insured Children Hospitalized With Traumatic Brain Injury

OBJECTIVES

To describe the prevalence of postdischarge outpatient rehabilitation among Medicaid-insured children hospitalized with a traumatic brain injury (TBI) and to identify factors associated with receipt of services.

METHODS

Retrospective cohort of children <21 years, hospitalized for a TBI between 2007 and 2012, from a national Medicaid claims database. Outcome measures were receipt of outpatient rehabilitation (physical, occupational, or speech therapies or physician visits to a rehabilitation provider) 1 and 3 years after discharge. Multivariable regression analyses determined the association of demographic variables, injury severity, and receipt of inpatient services with receipt of outpatient rehabilitation at 1 and 3 years. The mean number of services was compared between racial/ethnic groups.

RESULTS

Among 9361 children, only 29% received any type of outpatient rehabilitation therapy during the first year after injury, although 62% sustained a moderate to severe TBI. The proportion of children receiving outpatient therapies declined to 12% in the second and third years. The most important predictor of receipt of outpatient rehabilitation was receipt of inpatient therapies or consultation with a rehabilitation physician during acute care. Compared with children of other racial/ethnic groups, Hispanic children had lower rates of receipt of outpatient speech therapy.

CONCLUSIONS

Hospitalized children who received inpatient assessment of rehabilitation needs were more likely to continue outpatient rehabilitation care. Hispanic children with TBI were less likely than non-Hispanics to receive speech therapy. Interventions to increase inpatient rehabilitation during acute care might increase outpatient rehabilitation and improve outcomes for all children.

Adaptive functioning following pediatric traumatic brain injury: Relationship to executive function and processing speed

OBJECTIVE

Pediatric traumatic brain injury (TBI) may affect children's ability to perform everyday tasks (i.e., adaptive functioning). Guided by the American Association for Intellectual and Developmental Disabilities (AAIDD) model, we explored the association between TBI and adaptive functioning at increasing levels of specificity (global, AAIDD domains, and subscales). We also examined the contributions of executive function and processing speed as mediators of TBI's effects on adaptive functioning.

METHOD

Children (ages 8-13) with severe TBI (STBI; n = 19), mild-moderate TBI (MTBI; n = 50), or orthopedic injury (OI; n = 60) completed measures of executive function (TEA-Ch) and processing speed (WISC-IV) an average of 2.7 years postinjury (SD = 1.2; range: 1-5.3). Parents rated children's adaptive functioning (ABAS-II, BASC-2, CASP).

RESULTS

STBI had lower global adaptive functioning (η2 = .04-.08) than the MTBI and OI groups, which typically did not differ. Deficits in the STBI group were particularly evident in the social domain, with specific deficits in social participation, leisure, and social adjustment (η2 = .06-.09). Jointly, executive function and processing speed were mediators of STBI's effects on global adaptive functioning and in conceptual and social domains. In the STBI group, executive function mediated social functioning, and processing speed mediated social participation.

CONCLUSIONS

Children with STBI experience deficits in adaptive functioning, particularly in social adjustment, with less pronounced deficits in conceptual and practical skills. Executive function and processing speed may mediate the effects of STBI on adaptive functioning. Targeting adaptive functioning and associated cognitive deficits for intervention may enhance quality of life for pediatric TBI survivors. (PsycINFO Database Record

The UCLA study of Predictors of Cognitive Functioning Following Moderate/Severe Pediatric Traumatic Brain Injury

OBJECTIVES

Following pediatric moderate-to-severe traumatic brain injury (msTBI), few predictors have been identified that can reliably identify which individuals are at risk for long-term cognitive difficulties. This study sought to determine the relative contribution of detailed descriptors of injury severity as well as demographic and psychosocial factors to long-term cognitive outcomes after pediatric msTBI.

METHODS

Participants included 8- to 19-year-olds, 46 with msTBI and 53 uninjured healthy controls (HC). Assessments were conducted in the post-acute and chronic stages of recovery. Medical record review provided details regarding acute injury severity. Parents also completed a measure of premorbid functioning and behavioral problems. The outcome of interest was four neurocognitive measures sensitive to msTBI combined to create an index of cognitive performance.

RESULTS

Results indicated that none of the detailed descriptors of acute injury severity predicted cognitive performance. Only the occurrence of injury, parental education, and premorbid academic competence predicted post-acute cognitive functioning. Long-term cognitive outcomes were best predicted by post-acute cognitive functioning.

DISCUSSION

The findings suggest that premorbid factors influence cognitive outcomes nearly as much as the occurrence of a msTBI. Furthermore, of youth with msTBI who initially recover to a level of moderate disability or better, a brief cognitive battery administered within several months after injury can best predict which individuals will experience poor long-term cognitive outcomes and require additional services.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury

OBJECTIVE

To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI).

STUDY DESIGN

Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income.

RESULTS

There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs.

CONCLUSIONS

Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.

Does Health Literacy Level Influence the Effectiveness of a Kiosk-Based Intervention Delivered in the Pediatric Emergency Department?

OBJECTIVE

This study assesses parents' literacy skills and evaluates how literacy levels influenced the effectiveness of a health communication intervention designed to improve safety knowledge in low-income, urban families.

METHODS

A total of n = 450 parents of children aged 4 to 66 months completed the Rapid Estimate of Adult Literacy in Medicine (REALM) and participated in a randomized trial of an injury prevention intervention delivered via computer kiosk in a pediatric emergency department. A safety knowledge test was administered by telephone 2 to 4 weeks later.

RESULTS

More than one-third of parents were assessed by the REALM to have marginal (30%) or inadequate (8%) reading levels; the remaining 62% of parents had adequate reading levels. REALM scores were independently associated with knowledge gains for poison storage and smoke alarms.

CONCLUSIONS

Participants reading level had an independent and significant effect on safety knowledge outcomes. Literacy level should be considered in all patient education efforts.

Pediatric spinal injury in the US: epidemiology and disparities

OBJECT

In the US, race and economic status have pervasive associations with mechanisms of injury, severity of injury, management, and outcomes of trauma. The goal of the current study was to examine these relationships on a large scale in the setting of pediatric spinal injury.

METHODS

Admissions for spinal fracture without or with spinal cord injury (SCI), spinal dislocation, and SCI without radiographic abnormality were identified in the Kids' Inpatient Database (KID) and the National Trauma Data Bank (NTDB) registry for 2009. Patients ranged in age from birth up to 21 years. Data from the KID were used to estimate nationwide annual incidences. Data from the NTDB were used to describe patterns of injury in relation to age, race, and payor, with corroboration from the KID. Multiple logistic regression was used to model rates of mortality and spinal fusion.

RESULTS

In 2009, the estimated incidence of hospital admission for spinal injury in the US was 170 per 1 million in the population under 21 years of age. The incidence of SCI was 24 per 1 million. Incidences varied regionally. Adolescents predominated. Patterns of injury varied by age, race, and payor. Black patients were more severely injured than patients of other races as measured by Injury Severity Scale scores. Among black patients with spinal injury in the NTDB, 23.9% suffered firearm injuries; only 1% of white patients suffered firearm injuries. The overall mortality rate in the NTDB was 3.9%. In a multivariate analysis that included a large panel of clinical and nonclinical factors, black race retained significance as a predictor of mortality (p = 0.006; adjusted OR 1.571 [1.141-2.163]). Rates of spinal fusion were associated with race and payor in the NTDB data and with payor in the KID: patients with better insurance underwent spinal fusion at higher rates.

CONCLUSIONS

The epidemiology of pediatric spinal injury in the US cannot be understood apart from considerations of race and economic status.

Social problem-solving and social adjustment in paediatric traumatic brain injury

OBJECTIVE

Little is known regarding the predictors of social deficits that occur following childhood traumatic brain injury (TBI). The current study sought to investigate social problem solving (SPS) and its relationship to social adjustment after TBI.

METHODS

Participants included 8-13 year old children, 25 with severe TBI, 57 with complicated mild-to-moderate TBI and 61 with orthopaedic injuries (OI). Children responded to scenarios involving negative social situations by selecting from a fixed set of choices their causal attribution for the event, their emotional reaction to the event and how they would behave in response. Parent ratings of social behaviours and classmate friendship nominations and sociometric ratings were obtained for a sub-set of all participants.

RESULTS

Children with severe TBI were less likely than children with OI to indicate they would attribute external blame or respond by avoiding the antagonist; they were more likely to indicate they would feel sad and request adult intervention. Although several SPS variables had indirect effects on the relationship between TBI and social adjustment, clinical significance was limited.

CONCLUSIONS

The findings suggest that, while children with TBI display atypical SPS skills, SPS cannot be used in isolation to accurately predict social adjustment.

Self-awareness of peer-rated social attributes in children with traumatic brain injury

OBJECTIVE

This study investigated self-awareness of peer-rated social attributes and its relations to executive function (EF), theory of mind (TOM), and psychosocial adjustment in children with traumatic brain injury (TBI).

METHODS

Self- and peer perceptions of classroom social behavior were assessed for 87 children 8-13 years of age: 15 with severe TBI, 40 with complicated mild/moderate TBI, and 32 with orthopedic injury. Participants completed measures of EF and TOM, and parents rated children's psychosocial adjustment.

RESULTS

Self-ratings of classroom social behavior did not differ between injury groups. Self- and peer ratings generally agreed, although children with severe TBI rated themselves as less rejected/victimized than did their peers. Higher EF predicted better self- and peer ratings and smaller self-peer discrepancies, which in turn predicted better adjustment.

CONCLUSIONS

Children with TBI show variable social self-awareness, which relates to EF and adjustment. Future studies should identify additional factors that contribute to limited insight.

Median Household Income: Association with Mortality in Children on Chronic Ventilation at Home Secondary to Bronchopulmonary Dysplasia

Objective: The aim of this study was to determine if living in a lower income neighborhood is associated with mortality of patients with bronchopulmonary dysplasia (BPD) on home ventilation. Methods: Patients were divided into two groups by their ZIP code-based annual household income (Z-AHI), their year of birth, and the median state household income. Survival, liberation from ventilation, and decannulation rates were analyzed between the groups. Results: Over 27 years, 94 patients met our inclusion criteria: 58 (61.7%) were in the group with lower Z-AHI, and 36 (38.3%) were in the group with the Z-AHI above the median state household. Of the patients who died, 14/15 were in the lower Z-AHI group (p=0.003). Survival probability at 60 months of age showed no significant difference between the two groups: 81% [95% CI 70.9, 91.1] for the group with the Z-AHI below the median state household, and 100% [95% CI 100.0, 90.3] for the group with higher Z-AHI (p=0.31). Conclusions: The results of this study are descriptive, as the cause of the association between mortality rate and living in an area with lower household income is not yet understood. The difference in mortality rates between groups above and below the median state income suggests a serious health disparity, which warrants further study. Additional understanding of this effect requires more complete and direct measurement of socioeconomic status and individual characteristics, and better understanding of local environmental conditions.

Functional plasticity in childhood brain disorders: when, what, how, and whom to assess

At every point in the lifespan, the brain balances malleable processes representing neural plasticity that promote change with homeostatic processes that promote stability. Whether a child develops typically or with brain injury, his or her neural and behavioral outcome is constructed through transactions between plastic and homeostatic processes and the environment. In clinical research with children in whom the developing brain has been malformed or injured, behavioral outcomes provide an index of the result of plasticity, homeostasis, and environmental transactions. When should we assess outcome in relation to age at brain insult, time since brain insult, and age of the child at testing? What should we measure? Functions involving reacting to the past and predicting the future, as well as social-affective skills, are important. How should we assess outcome? Information from performance variability, direct measures and informants, overt and covert measures, and laboratory and ecological measures should be considered. In whom are we assessing outcome? Assessment should be cognizant of individual differences in gene, socio-economic status (SES), parenting, nutrition, and interpersonal supports, which are moderators that interact with other factors influencing functional outcome.

An Evaluation of Trauma Outcomes Related to Insurance Status in Patients Requiring Prehospital Helicopter Transport

Introduction

Disparities in access to medical care and outcomes of medical treatment related to insurance status are documented. However, little attention has been given to the effect of health care funding status on outcomes in trauma patients.

Hypothesis/Problem

This study evaluated if adult trauma patients who arrived by air transport to a trauma center had different clinical outcomes based on their health insurance status.

Methods

A retrospective analysis was performed of all adult trauma patients arriving by prehospital flight services to a Level I Trauma Center over a 5-year period. Patients were classified as unfunded or funded based on health insurance status. Injury severity scores (ISS) were compared, while the end points evaluated in the study included duration of stay in the intensive care unit (ICU), duration of hospitalization, and mortality.

Results

A total of 1,877 adult patients met inclusion criteria for the study, with 14% (n = 259) classified as unfunded and 86% (n = 1,618) classified as funded. Unfunded patients compared to funded patients had a significantly lower average ISS (12.82 vs 15.56; P < .001) but a significantly higher mortality rate (16.6% vs 10.7%; P < .01) and a 1.54 relative risk of death (95% CI, 1.136-2.098). Neither mean ICU stay (3.44 days vs 4.98 days; P = .264) nor duration of hospitalization (11.18 days vs 13.34 days; P = .382) was significantly different when controlling for ISS.

Conclusion

Unfunded health insurance status is associated with worse outcomes following less significant injury. Further investigation of baseline health disparities for identification and early intervention may improve outcomes. Additionally, these findings may have implications for the health systems of other countries that lack universal health care coverage.

GurienLA, ChesireDJ, KoonceSL, BurnsJBJr. An evaluation of trauma outcomes related to insurance status in patients requiring prehospital helicopter transport. Prehosp Disaster Med. 2014;29(6):1-4.

Executive functions and theory of mind as predictors of social adjustment in childhood traumatic brain injury

This study examined whether executive function and theory of mind mediate the effects of pediatric traumatic brain injury (TBI) on social adjustment, relative to children with orthopedic injury (OI). Participants included 19 children with severe TBI, 41 children with complicated mild/moderate TBI, and 57 children with OI. They completed measures of executive function, as well as cognitive, affective, and conative theory of mind. Parents provided ratings of children's social adjustment. Children with severe TBI performed more poorly than children with OI on executive function and theory of mind tasks and were rated by parents as having more behavioral symptoms and worse communication and social skills. Executive function and theory of mind were positively correlated with social skills and communication skills, and negatively correlated with behavioral symptoms. In multiple mediator models, theory of mind and executive function were not significant direct predictors of any measure of social adjustment, but mediated the association between injury and adjustment for children with severe TBI. Theory of mind was a significant independent mediator when predicting social skills, but executive function was not. TBI in children, particularly severe injury, is associated with poor social adjustment. The impact of TBI on children's social adjustment is likely mediated by its effects on executive function and theory of mind.

A national, cross-sectional survey of children's hospital-based safety resource centres

OBJECTIVE

To describe the location, staffing, clientele, safety product disbursement patterns, education provided and sustainability of safety resource centres (SRCs) in US children's hospitals.

METHODS

A cross-sectional survey was distributed to children's hospital-based SRC directors. Survey categories included: funding sources, customer base, items sold, items given free of charge, education provided and directors' needs.

RESULTS

32/38 (84.2%) SRC sites (affiliated with 30 hospitals) completed the survey. SRCs were in many hospital locations including lobby (28.1%), family resource centres (12.5%), gift shop/retail space (18.8%), mobile units (18.8%) and patient clinics (12.5%). 19% of respondents reported that their SRC was financially self-sustainable. Sales to patients predominated (mean of 44%); however, hospital employees made up a mean of 20% (range 0-60%) of sales. 78.1% of SRCs had products for children with special healthcare needs. Documentation kept at SRC sites included items purchased (96.9%), items given free of charge (65.6%) and customer demographics (50%). 56.3% of SRCs provided formal injury prevention education classes. The SRCs' directors' most important needs were finances (46.9%), staffing (50%) and space (46.9%). All of the directors were 'somewhat interested' or 'very interested' in each of the following: creation of a common SRC listserv, national SRC data bank and multisite SRC research platform.

CONCLUSIONS

SRCs are located in many US children's hospitals, and can be characterised as heterogeneous in location, products sold, data kept and ability to be financially sustained. Further research is needed to determine best practices for SRCs to maximise their impact on injury prevention.