A predictive model for perinatal hypoxic ischemic encephalopathy using linked maternal and neonatal hospital data.

PURPOSE: To build an evidence-based model to estimate case-specific risk of perinatal hypoxic ischemic encephalopathy. METHODS: A retrospective, cross-sectional study of all births in Hawaii, Michigan, and New Jersey between 2010 and 2015, using linked maternal labor/delivery and neonatal birth records. Stepwise logistic regression and competitive Akaike information criterion were used to identify the most parsimonious model. Predictive ability of the model was measured with bootstrapped optimism-adjusted area under the ROC curve. RESULTS: Among 836,216 births there were 376 (0.45 per 1000) cases of hypoxic ischemic encephalopathy. The final model included 28 variables, 24 associated with increased risk, and 4 that were protective. The optimism-adjusted area under the ROC curve was 0.84. Estimated risk in the study population ranged from 1 in ∼323,000 to 1 in 2.5. The final model confirmed known risk factors (e.g., sentinel events and shoulder dystocia) and identified novel risk factors, such as maternal race and insurance status. CONCLUSION: Our study shows that risk of perinatal hypoxic ischemic encephalopathy injury can be estimated with high confidence. Our model fills a notable gap in the study of hypoxic ischemic encephalopathy prevention: the estimation of risk, particularly in the United States population which is unique with respect to racial and socioeconomic disparities.

Injuries Due to Law Enforcement Use of Force in the United States, 2006-2015: Trends in Severity and by Race.

PURPOSE: The purpose of the study was to assess incidence and severity of hospital reported injuries related to law enforcement Use of Force (UoF) in the US over time, and by race. METHODS: Data from the National Emergency Department Sample from the Healthcare Cost and Utilization Project and the National Electronic Injury Surveillance System (NEISS-AIP) from US Consumer Product Safety Commission were queried to identify UoF injuries. Regression analysis, t-tests, and chi-square tests were used in the analysis. RESULTS: Between 2006-15, there were 529,259 emergency department admissions for UoF injury in the NEDS, and 870,779 admissions in the NEISS-AIP. In a model adjusting for year, sex, and age, the Injury Severity Score increased by 1.1% annually (p<0.0001). Black people were 6 times as likely to be admitted to the ED as White people or Native Americans/Alaska Natives, and 25 times as likely as Asians/Pacific Islanders. Black patients were 4 times as likely as White patients to be admitted as inpatients. Per arrest rate by race using FBI uniform crime reporting data, Black arrestees were 2.5-3.1 times as likely as any other race to be hospitalized for UoF injury. CONCLUSION: The results of the study demonstrate that US law enforcement are injuring civilians more frequently and severely over time, and that Black people are disproportionately affected.

Response to "Scrutinizing the causal link between excited delirium syndrome and restraint - a commentary on: 'The role of restraint in fatal excited delirium: a research synthesis and pooled analysis' by E.M.F. Strömmer, W. Leith, M.P. Zeegers and M.D. Freeman".

de Boer et al. criticize the conclusions in our 2020 paper on the validity of Excited Delirium Syndrome (ExDS) as "egregiously misleading." Our conclusion was that there "is no existing evidence that indicates that ExDS is inherently lethal in the absence of aggressive restraint." The basis for de Boer and colleague's criticism of our paper is that the ExDS literature does not provide an unbiased view of the lethality of the condition, and therefore the true epidemiologic features of ExDS cannot be determined from what has been published. The criticism is unrelated to the goals or methods of the study, however. Our stated purpose was to investigate "how the term ExDS has evolved in the literature and been endowed with a uniquely lethal quality," and whether there is "evidence for ExDS as a unique cause of a death that would have occurred regardless of restraint, or a label used when a restrained and agitated person dies, and which erroneously directs attention away from the role of restraint in explaining the death." We cannot fathom how de Boer et al. missed this clearly stated description of the study rationale, or why they would endorse a series of fallacious and meaningless claims that gave the appearance that they failed to grasp the basic design of the study. We do acknowledge and thank these authors for pointing out 3 minor citation errors and an equally minor table formatting error (neither of which altered the reported results and conclusions in the slightest), however.

The role of restraint in fatal excited delirium: a research synthesis and pooled analysis.

The purpose of the present study was to perform a comprehensive scientific literature review and pooled data risk factor analysis of excited delirium syndrome (ExDS) and agitated delirium (AgDS). All cases of ExDS or AgDS described individually in the literature published before April 23, 2020 were used to create a database of cases, including demographics, use of force, drug intoxication, mental illness, and survival outcome. Odds ratios were used to quantify the association between death and diagnosis (ExDS vs. AgDS) across the covariates. There were 61 articles describing 168 cases of ExDS or AgDS, of which 104 (62%) were fatal. ExDS was diagnosed in 120 (71%) cases, and AgDS in 48 (29%). Fatalities were more likely to be diagnosed as ExDS (OR: 9.9, p < 0.0001). Aggressive restraint (i.e. manhandling, handcuffs, and hobble ties) was more common in ExDS (ORs: 4.7, 14, 29.2, respectively, p < 0.0001) and fatal cases (ORs: 7.4, 10.7, 50, respectively, p < 0.0001). Sedation was more common in AgDS and survived cases (OR:11, 25, respectively, p < 0.0001). The results of the study indicate that a diagnosis of ExDS is far more likely to be associated with both aggressive restraint and death, in comparison with AgDS. There is no evidence to support ExDS as a cause of death in the absence of restraint. These findings are at odds with previously published theories indicating that ExDS-related death is due to an occult pathophysiologic process. When death has occurred in an aggressively restrained individual who fits the profile of either ExDS or AgDS, restraint-related asphyxia must be considered a likely cause of the death.

Estimating the number of traffic crash-related cervical spine injuries in the United States; An analysis and comparison of national crash and hospital data.

BACKGROUND: Cervical spine injury is a common result of traffic crashes, and such injuries range in severity from minor (i.e. sprain/strain) to moderate (intervertebral disk derangement) to serious and greater (fractures, dislocations, and spinal cord injuries). There are currently no reliable estimates of the number of crash-related spine injuries occurring in the US annually, although several publications have used national crash injury samples as a basis for estimating the frequency of both cervical and lumbar spinal disk injuries occurring in lower speed rear impact crashes. PURPOSE: To develop a reliable estimate of the number of various types of cervical spine injuries occurring in the US by comparing data from national crash injury to national hospital ED and inpatient samples. STUDY DESIGN: Comparative cross-sectional METHODS: Cervical spine injury data were accessed, analyzed, and compared from 3 national databases; the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS), Nationwide Emergency Department Sample (NEDS), and the Nationwide Inpatient Sample (NIS). RESULTS: It is estimated that there are approximately 869,000 traffic crash-related cervical spine injuries seen in hospitals in the US annually, including around 841,000 sprain/strain (whiplash) injuries, 2800 spinal disk injuries, 23,500 fractures, 2800 spinal cord injuries, and 1500 dislocations. Because of a highly restrictive inclusion criteria for both crash and injury types, as well as a very small sample size, the NASS-CDS underestimated all types of crash-related cervical spine injuries seen in US hospital emergency departments by 84 %. The injury type with the largest degree of underestimation in the NASS-CDS was cervical disk injuries, which were estimated at an 88 % lower frequency than in the NEDS. National insurance claim data, which include cases of cervical disk injury diagnosed both in and outside of the ED, indicate that the NEDS likely undercounts cervical disk injuries by 92 %, and thus the NASS-CDS correspondingly undercounts such injuries by 99 % or more. CONCLUSIONS: Because of a limited sample size and restrictive criteria for both crash and injury inclusion, the NASS-CDS cannot be used to estimate the number of crash-related spinal injuries of any type or severity in the US. The most inappropriate use of the database is for estimating the number of spinal injuries resulting from low speed rear impact collisions, as the NASS-CDS samples fewer than 1 in 100,000 of the cervical spine injuries of any type occurring in low speed rear impact collisions.

Diagnostic Accuracy of Videofluoroscopy for Symptomatic Cervical Spine Injury Following Whiplash Trauma.

BACKGROUND: Intervertebral instability is a relatively common finding among patients with chronic neck pain after whiplash trauma. Videofluoroscopy (VF) of the cervical spine is a potentially sensitive diagnostic tool for evaluating instability, as it offers the ability to examine relative intervertebral movement over time, and across the entire continuum of voluntary movement of the patient. At the present time, there are no studies of the diagnostic accuracy of VF for discriminating between injured and uninjured populations. METHODS: Symptomatic (injured) study subjects were recruited from consecutive patients with chronic (>6 weeks) post-whiplash pain presenting to medical and chiropractic offices equipped with VF facilities. Asymptomatic (uninjured) volunteers were recruited from family and friends of patients. An ethical review and oversight were provided by the Spinal Injury Foundation, Broomfield, CO. Three statistical models were utilized to assess the sensitivity, specificity, positive and negative predictive values (PPV and NPV) of positive VF findings to correctly discriminate between injured and uninjured subjects. RESULTS: A total of 196 subjects (119 injured, 77 uninjured) were included in the study. All three statistical models demonstrated high levels of sensitivity and specificity (i.e., receiver operating characteristic (ROC) values of 0.71 to 0.95), however, the model with the greatest practical clinical utility was based on the number of abnormal VF findings. For 2+ abnormal VF findings, the ROC was 0.88 (93% sensitivity, 79% specificity) and the PPV and NPV were both 88%. The highest PPV (1.0) was observed with 4+ abnormal findings. CONCLUSIONS: Videofluoroscopic examination of the cervical spine provides a high degree of diagnostic accuracy for the identification of vertebral instability in patients with chronic pain stemming from whiplash trauma.

The association between gabapentin and suicidality in bipolar patients.

The aims of this study were to assess the association between gabapentin and suicidality in patients diagnosed with bipolar disorder (BD) and to determine whether the risk is greater relative to patients prescribed lithium. This retrospective observational study utilizes US population-based claims data assembled by PharMetrics Inc., comprising 47 918 patients diagnosed with BD. Patients were included if they were at least 18 years old and initiated a new monotherapy prescription of either gabapentin (n=2421) or lithium (n=3101). Patients were followed for up to 1 year. Gabapentin patients contributed 915.8 person-years (PY) of follow-up time; lithium patients contributed 1421.3 PY. There were 21 suicide/self-harm events in the gabapentin group and 16 in the lithium group. Unadjusted incidence rates were 22.9 and 11.3/1000 PY in the gabapentin and lithium groups, respectively (P=0.03). After adjusting for concomitant medications, comorbid diagnoses, age, sex, and history of suicide/self-harm, the hazard ratio was 2.3 (95% confidence interval: 1.2-4.5). A propensity score-matched analysis accounting for pre-existing illnesses and medications supports this finding, with an adjusted hazard ratio of 2.1 (95% confidence interval: 1.02-4.5). Relative to lithium, the use of gabapentin is significantly associated with a doubling of the risk of suicidality in patients diagnosed with BD.

Clinical outcomes and healthcare use associated with optimal ESRD starts.

OBJECTIVES: To assess the association between optimal end-stage renal disease (ESRD) starts and clinical and utilization outcomes in an integrated healthcare delivery system. STUDY DESIGN: Retrospective observational cohort study in 6 regions of an integrated healthcare delivery system, 2011-2013. METHODS: Propensity score techniques were used to match 1826 patients who experienced an optimal start of renal replacement therapy (initial therapy of hemodialysis via an arteriovenous fistula or graft, peritoneal dialysis, or pre-emptive transplant) to 1826 patients who experienced a nonoptimal start (hemodialysis via a central venous catheter). Outcomes included 12-month rates of sepsis, mortality, and utilization (inpatient stays, total inpatient days, emergency department visits, and outpatient visits to primary care and specialty care). RESULTS: Optimal starts were associated with a 65% reduction in sepsis (odds ratio, 0.35; 95% CI, 0.29-0.42) and a 56% reduction in 12-month mortality (hazard ratio, 0.44; 95% CI, 0.36-0.53). Optimal starts were also associated with lower utilization, except for nephrology visits. Large utilization differences were observed for total inpatient days (9.4 for optimal starts vs 27.5 for nonoptimal starts; relative rate [RR], 0.45; 95% CI, 0.38-0.52) and outpatient visits for specialty care other than nephrology or vascular surgery (12.5 vs 18.3, respectively; RR, 0.62; 95% CI, 0.53-0.74). CONCLUSIONS: Compared with patients with nonoptimal starts, patients with optimal ESRD starts have lower morbidity and mortality and less use of inpatient and outpatient care. Late-stage chronic kidney disease and ESRD care in an integrated system may be associated with greater benefits than those previously reported in the literature.

A multistate population-based analysis of linked maternal and neonatal discharge records to identify risk factors for neonatal brachial plexus injury.

OBJECTIVE: To evaluate the interaction and contribution of maternal and fetal risk factors associated with neonatal brachial plexus injury (BPI). METHODS: In a case-control study, matched maternal and neonatal discharge records were accessed from US State Inpatient Databases for New Jersey (2010-2012), Michigan (2010-2011), and Hawaii (2010-2011). Univariate and multivariate logistic regressions were used to evaluate associations between risk factors and BPI. Area under the receiver operating characteristic curve was used to build predictive models, including two stratified models evaluating deliveries among obese and diabetic cohorts. RESULTS: Among 376 325 deliveries, BPI was diagnosed in 274 (0.1%). Significant BPI risk factors included maternal obesity (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.7-4.4), maternal diabetes (OR 4.6, 95% CI 3.0-7.0), use of forceps (OR 4.6, 95% CI 2.3-9.0), and vacuum assistance (OR 2.3, 95% CI 1.7-3.3). After adjusting for shoulder dystocia and other predictive factors, cesarean reduced the risk of BPI by 88% (OR 0.1, 95% CI 0.07-0.2). When stratified by obesity and diabetes, the ORs for BPI increased significantly for macrosomia, forceps, and vacuum assistance. CONCLUSION: The analysis confirms and quantifies more precisely the impact of risk factors for neonatal BPI, and provides a reliable basis for evidence-based clinical decision-making models.

Personal health record use for children and health care utilization: propensity score-matched cohort analysis.

OBJECTIVES: To examine the association between caregiver personal health record (PHR) use and health care utilization by pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective observational cohort study of 2286 pediatric members aged six months to 2.5 years of Kaiser Permanente Hawaii and Northwest Regions in 2007-2011, using propensity score matching methods and t and chi-square tests to examine associations between PHR use and health care utilization. We used ANOVA to examine utilization across quartiles of PHR use. MAIN OUTCOME MEASURES: Outpatient clinic visits, telephone encounters, and emergency department visits. RESULTS: PHR-registered children, compared with propensity score-matched nonregistered children, had 21% (95% CI, 14-28; P < .0001) more outpatient clinic visits and 26% (95% CI, 16-37; P < .0001) more telephone encounters. Utilization differences were more pronounced with nonprimary care providers than with primary care providers. Outpatient clinic visits and telephone encounters increased among the quartile with the highest PHR use; no utilization differences occurred in the 3 lowest-use quartiles. CONCLUSIONS: PHR use by caregivers was associated with statistically significant increases in outpatient clinic visits and telephone encounters among pediatric patients.

Injury pattern as an indication of seat belt failure in ejected vehicle occupants.

Prior authors have suggested that when occupant ejection occurs in association with a seat belt failure, entanglement of the outboard upper extremity (OUE) with the retracting shoulder belt will invariably occur, leaving injury pattern evidence of belt use. In the present investigation, the authors assessed this theory using data accessed from the NASS-CDS for ejected front seat occupants of passenger vehicles. Logistic regression models were used to assess the associations between seat belt failure status and injuries. Injury types associated with seat belt failure were significant OUE and head injuries (OR = 3.87, [95% CI 1.2, 13.0] and 3.1, [95% CI 1.0, 9.7], respectively). The two injury types were found to be a predictor of seat belt use and subsequent failure only if combined with a high (≥0.8) precrash probability of belt use. The injury pattern associated with a seat belt failure-related ejection has limited use in the forensic investigation of crash-related ejections.

Head and neck injury patterns in fatal falls: epidemiologic and biomechanical considerations.

Fatal falls often involve a head impact, which are in turn associated with a fracture of the skull or cervical spine. Prior authors have noted that the degree of inversion of the victim at the time of impact is an important predictor of the distribution of skull fractures, with skull base fractures more common than skull vault fractures in falls with a high degree of inversion. The majority of fatal fall publications have focused on skull fractures, and no research has described the association between fall circumstances and the distribution of fractures in the skull and neck. In the present study, we accessed data regarding head and neck fractures resulting from fatal falls from a Swedish autopsy database for the years 1992-2010, for the purposes of examining the relationships between skull and cervical spine fracture distribution and the circumstances of the fatal fall. Out of 102,310 medico-legal autopsies performed there were 1008 cases of falls associated with skull or cervical spine fractures. The circumstances of the falls were grouped in 3 statistically homogenous categories; falls occurring at ground level, falls from a height of <3 m or down stairs, and falls from ≥3 m. Only head and neck injuries and fractures that were associated with the fatal CNS injuries were included for study, and categorized as skull vault and skull base fractures, upper cervical injuries (C0-C1 dislocation, C1 and C2 fractures), and lower cervical fractures. Logistic regression modeling revealed increased odds of skull base and lower cervical fracture in the middle and upper fall severity groups, relative to ground level falls (lower cervical <3 m falls, OR = 2.55 [1.32, 4.92]; lower cervical ≥3 m falls, OR = 2.23 [0.98, 5.08]; skull base <3 m falls, OR = 1.82 [1.32, 2.50]; skull base ≥3 m falls, OR = 2.30 [1.55, 3.40]). C0-C1 dislocations were strongly related to fall height, with an OR of 8.3 for ≥3 m falls versus ground level. The findings of increased odds of skull base and lower cervical spine fracture in falls from a height are consistent with prior observations that the risk of such injuries is related to the degree of victim inversion at impact. The finding that C0-C1 dislocations are most common in falls from more than 3 m is unique, an indication that the injuries likely result from high energy shear forces rather than pure tension, as previously thought.