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OBJECTIVE: We investigated the trends of blood absolute monocyte count (AMC) over 72 h after suspecting necrotizing enterocolitis (NEC). STUDY DESIGN: A single center, retrospective study, the AMC was plotted over 72 h after NEC evaluation. Receiver operating characteristic (ROC) curve analysis assessed change in AMC to identify absence of NEC and different NEC stages. RESULTS: In 130 infants, the AMC decreased in patients with NEC stage 2 or 3. Stages 2 and 3 NEC experienced a drop in AMC compared to an increase in no NEC, possible NEC, or positive culture (p < 0.05). AMC increase 24% or less can differentiate NEC stage 2/3 from possible NEC with an area under the curve (AUC) of 0.78. While decrease of more than 32% can differentiate stage 2/3 vs. possible or no NEC with AUC of 0.71. DISCUSSION/CONCLUSIONS: A decrease in AMC can be an adjunct biomarker to confirm the diagnosis of NEC.
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PURPOSE: We aim to estimate the odds of UTI-related hospital care in spina bifida (SB) patients aged 18 to 25 years as compared with patients with SB in adolescence (11-17 years) or adulthood (26-35 years). We hypothesize that patients with SB in the typical transitional age, 18 to 25 years, will have higher odds of UTI-related hospital care as compared to adolescent SB patients or adult SB patients. MATERIALS AND METHODS: Using Cerner Real-World Data, we performed a retrospective cohort analysis comparing SB patients to age- and gender-matched controls. SB cases between 2015 and 2021 were identified and compared in 3 cohorts: 11 to 17 years (adolescents), 18 to 25 years (young adults [YA]), and 26 to 35 years (adults). Logistic regression analysis was used to characterize the odds of health care utilization. RESULTS: Of the 5497 patients with SB and 77,466 controls identified, 1839 SB patients (34%) and 3275 controls (4.2%) had at least 1 UTI encounter. UTI-related encounters as a proportion of all encounters significantly increased with age in SB patients (adolescents 8%, YA 12%, adult 15%; P < .0001). Adjusting for race, sex, insurance, and comorbidities, the odds of a UTI-related encounter in YA with SB were significantly higher than for adolescents with SB (adolescent odds ratio = 0.65, 95% CI: 0.57-0.75, P < .001). YA had lower odds of a UTI-related encounter as compared with adults with SB (adult odds ratio = 1.31, 95% CI: 1.16-1.49, P < .001). CONCLUSIONS: YA with SB have higher odds of UTI-related hospital care than adolescents, but lower odds of UTI-related hospital care when compared with adults.
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BACKGROUND: Nurse practitioner (NP) burnout related to high patient-to-NP ratios needs to be addressed. OBJECTIVES: To survey inpatient pediatric NPs, assess burnout and characterize associated workload and support. DESIGN: Online cross-sectional survey conducted in three phases from March 2022 to August 2023. SUBJECTS AND SETTING: Inpatient specialty NPs from 32 hospitals. RESULTS: Fisher's exact test and logistic regression were implemented. A patient-to-provider (NP or resident) ratio of more than 5:1 was associated with NP burnout (OR = 3.5, 95% CI 1.0, 12.0 and OR = 4.1, 95% CI 1.1, 16.2, respectively, p < .05). Among NPs without burnout, 100% had organizational NP leadership (p = .012). INTERPRETATION: Though limited by a small convenience sample, a patient-to-provider ratio over 5:1 was associated with NP burnout, and NP leadership was protective. Further research of cost analysis, retention, and patient quality and safety measures are needed. CONCLUSION: Lower patient-to-NP ratios and NP leadership play a pivotal role in preventing burnout.
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Agotamiento Profesional , Liderazgo , Humanos , Agotamiento Profesional/prevención & control , Agotamiento Profesional/epidemiología , Estudios Transversales , Femenino , Masculino , Adulto , Admisión y Programación de Personal , Carga de Trabajo/psicología , Encuestas y Cuestionarios , Enfermeras Practicantes , Persona de Mediana Edad , Pacientes Internos/psicología , Pacientes Internos/estadística & datos numéricosRESUMEN
BACKGROUND: Nonoperative management (NOM) is the standard of care for the management of blunt liver and spleen injuries (BLSI) in the stable pediatric patient. Angiography with embolization (AE) is used as an adjunctive therapy in the management of adult BLSI patients, but it is rarely used in the pediatric population. In this planned secondary analysis, we describe the current utilization patterns of AE in the management of pediatric BLSI. METHODS: After obtaining IRB approval at each center, cohort data was collected prospectively for children admitted with BLSI confirmed on CT at 10 Level I pediatric trauma centers (PTCs) throughout the United States from April 2013 to January 2016. All patients who underwent angiography with or without embolization for a BLSI were included in this analysis. Data collected included patient demographics, injury details, organ injured and grade of injury, CT finding specifics such as contrast blush, complications, failure of NOM, time to angiography and techniques for embolization. RESULTS: Data were collected for 1004 pediatric patients treated for BLSI over the study period, 30 (3.0%) of which underwent angiography with or without embolization for BLSI. Ten of the patients who underwent angiography for BLSI failed NOM. For patients with embolized splenic injuries, splenic salvage was 100%. Four of the nine patients undergoing embolization of the liver ultimately required an operative intervention, but only one patient required hepatorrhaphy and no patient required hepatectomy after AE. Few angiography studies were obtained early during hospitalization for BLSI, with only one patient undergoing angiography within 1 hour of arrival at the PTC, and 7 within 3 hours. CONCLUSION: Angioembolization is rarely used in the management of BLSI in pediatric trauma patients with blunt abdominal trauma and is generally used in a delayed fashion. However, when implemented, angioembolization is associated with 100% splenic salvage for splenic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Embolización Terapéutica , Hígado , Bazo , Heridas no Penetrantes , Humanos , Embolización Terapéutica/métodos , Heridas no Penetrantes/terapia , Heridas no Penetrantes/diagnóstico por imagen , Bazo/lesiones , Bazo/irrigación sanguínea , Bazo/diagnóstico por imagen , Niño , Masculino , Femenino , Hígado/lesiones , Hígado/irrigación sanguínea , Hígado/diagnóstico por imagen , Adolescente , Angiografía , Preescolar , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Puntaje de Gravedad del Traumatismo , Traumatismos Abdominales/terapia , Traumatismos Abdominales/diagnóstico por imagen , Resultado del Tratamiento , Estados Unidos , Estudios ProspectivosRESUMEN
BACKGROUND: COVID-19 pandemic introduced significant challenges that may have exacerbated healthcare worker (HCW) burnout. To date, assessments of burnout during COVID-19 pandemic have been cross-sectional, limiting our understanding of changes in burnout. This longitudinal study assessed change across time in pediatric HCW burnout during the COVID-19 pandemic and whether demographic and psychological factors were associated with changes in burnout. METHODS: This longitudinal study included 162 physicians, physician assistants, nurses, and medical technicians within the emergency department (ED), intensive care, perioperative, and inter-hospital transport services in a children's hospital. HCW demographics, anxiety and personality traits were reported via validated measures. HCWs completed the Maslach Burnout Inventory in April 2020 and March 2021. Data were analyzed using generalized estimating equations. RESULTS: The percentage of HCWs reporting high emotional exhaustion and/or depersonalization burnout increased significantly across time (18.5% to 28.4%, P = 0.010). Factors associated with increased emotional exhaustion included working in the ED (P = 0.011) or perioperative department (P < 0.001), being a nurse or medical technician (P's < 0.001), not having children (P < 0.001), and low conscientiousness (P < 0.001). CONCLUSIONS: Pediatric HCW burnout significantly increased over 11-months of the COVID-19 pandemic. Results suggest that certain demographic and psychological factors may represent potential area to target for intervention for future pandemics. IMPACT: This longitudinal study revealed that the COVID-19 pandemic has had a significant impact on pediatric healthcare worker burnout. The percentage of healthcare workers reporting high levels of emotional exhaustion and depersonalization burnout increased significantly over 11-months of the COVID-19 pandemic. Results suggest that certain demographic and psychological factors may represent potential targets for future interventions.
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COVID-19 , Pandemias , Humanos , Niño , Estudios Longitudinales , Estudios Transversales , Agotamiento Psicológico , Encuestas y CuestionariosRESUMEN
BACKGROUND: Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture's demographics, clinical characteristics, and treatment patterns. METHODS: Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates. RESULTS: There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%). CONCLUSIONS: Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates. LEVEL OF EVIDENCE: Level III, retrospective study.
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Fracturas Abiertas , Traumatismos de la Mano , Masculino , Adulto , Humanos , Niño , Femenino , Estudios Retrospectivos , Fijación Interna de Fracturas/efectos adversos , Fracturas Abiertas/epidemiología , Fracturas Abiertas/cirugía , Fracturas Abiertas/complicaciones , Reducción Abierta/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Traumatismos de la Mano/epidemiología , Traumatismos de la Mano/terapia , Resultado del TratamientoRESUMEN
PURPOSE: Appendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time. METHODS: Demographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014-October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors. RESULTS: Of 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007). CONCLUSION: Retrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics. LEVEL OF EVIDENCE: IV.
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Apendicitis , Laparoscopía , Humanos , Niño , Masculino , Femenino , Apendicectomía/efectos adversos , Apendicectomía/métodos , Apendicitis/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Ombligo/cirugía , Laparoscopía/efectos adversos , Laparoscopía/métodos , Tiempo de Internación , DolorRESUMEN
BACKGROUND: Many children with blunt liver and/or spleen injury (BLSI) never bleed intraperitoneally. Despite this, decreases in hemoglobin are common. This study examines initial and follow up measured hemoglobin values for children with BLSI with and without evidence of intra-abdominal bleeding. METHODS: Children ≤18 years of age with BLSI between April 2013 and January 2016 were identified from the prospective ATOMAC+ cohort. Initial and follow up hemoglobin levels were analyzed for 4 groups with BLSI: (1) Non bleeding; (2) Bleeding, non transfused (3) Bleeding, transfused, and (4) Bleeding resulting in non operative management (NOM) failure. RESULTS: Of 1007 patients enrolled, 767 were included in one or more of four study cohorts. Of 131 non bleeding patients, the mean decrease in hemoglobin was 0.83 g/dL (+/-1.35) after a median of 6.3 [5.1,7.0] hours, (p = 0.001). Follow-up hemoglobin levels in patients with and without successful NOM were not different. For patients with an initial hemoglobin >9.25 g/dL, the odds ratio (OR) for NOM failure was 14.2 times less, while the OR for transfusion was 11.4 times less (p = 0.001). CONCLUSION: Decreases in hemoglobin are expected after trauma, even if not bleeding. A hemoglobin decrease of 2.15 g/dL [0.8 + 1.35] would still be within one standard deviation of a non bleeding patient. An initial low hemoglobin correlates with failure of NOM as well as transfusion, thereby providing useful information. By contrast, subsequent hemoglobin levels do not appear to guide the need for transfusion, nor correlate with failure of NOM. These results support initial hemoglobin measurement but suggest a lack of utility for routine rechecking of hemoglobin. LEVEL OF EVIDENCE: Level II Prognostic Study.
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Traumatismos Abdominales , Heridas no Penetrantes , Niño , Humanos , Bazo/lesiones , Estudios Prospectivos , Hemodilución , Hígado/lesiones , Heridas no Penetrantes/terapia , Heridas no Penetrantes/cirugía , Traumatismos Abdominales/complicaciones , Hemorragia/etiología , Hemorragia/terapia , Hemoglobinas , Estudios Retrospectivos , Puntaje de Gravedad del TraumatismoRESUMEN
BACKGROUND: Intercostal nerve cryoablation (cryoanalgesia) is increasingly used for pain control in minimally invasive repair of pectus excavatum (MIRPE) by Nuss procedure. Cryoanalgesia may lower core body temperature and increase the risk of postoperative infectious complications. We investigated cryoanalgesia effects on infectious complications following MIRPE. METHOD: We performed a retrospective review of patients undergoing MIRPE at our institution. Patients treated via multimodal analgesia with cryoanalgesia (Cryo) were compared to patients treated via multimodal analgesia +/- elastomeric pain pumps (Non-cryo). Core body and intraoperative minimum/maximum temperatures were recorded. Primary outcomes were wound infection and pneumonia; secondary outcome was length of stay (LOS). Fisher's Exact and Mann-Whitney U tests compared proportions and medians respectively, p-value ≤ 0.05 being significant. RESULTS: 80 patients were included, 35(43.7%) Cryo and 45(56.3%) Non-cryo. There were no significant differences in median [IQR] for age(15[13.3,16.0];p =0.86), number of bars inserted (2[1,2];p = 0.57), or operative time(123.5[98.3, 148.8]; p = 0.11) between the two groups. We found no significant differences in median [IQR] minimum temperature (35.4°C [35.0,35.8];p = 0.76), median change in intraoperative temperature (-0.13°C [-0.44,0.00];p = 0.94) or median recovery temperature (-1.10°C [-1.56,-0.65]; p = 0.59) between Cryo and Non-cryo. PACU temperature was significantly lower in the Cryo group, 36.4°C [36.2,36.6] p = 0.04. There were no postoperative wound infections in either group and no significant difference in incidence of postoperative pneumonia (8.57% versus 2.22%,p = 0.31) or median[IQR] for LOS (4[3,4];p = 0.57), between Cryo and Non-cryo patients. CONCLUSION: Although cryoanalgesia for MIRPE resulted in lower core body temperature, there appears to be no significant difference between Cryo and Non-Cryo patients for LOS or infectious complications.
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Criocirugía , Tórax en Embudo , Hipotermia , Adolescente , Niño , Criocirugía/efectos adversos , Criocirugía/métodos , Tórax en Embudo/cirugía , Humanos , Hipotermia/complicaciones , Hipotermia/prevención & control , Nervios Intercostales/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Dolor Postoperatorio/terapia , Estudios RetrospectivosRESUMEN
Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(ß) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.
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Maltrato a los Niños , Traumatismos Craneocerebrales , Violencia de Pareja , Niño , Traumatismos Craneocerebrales/complicaciones , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/epidemiología , Humanos , Lactante , Abuso Físico , Factores de RiesgoAsunto(s)
Algoritmos , Maltrato a los Niños/diagnóstico , Abuso Físico , Heridas y Lesiones/diagnóstico , Heridas y Lesiones/etiología , Adolescente , Niño , Preescolar , Toma de Decisiones Clínicas , Servicio de Urgencia en Hospital , Humanos , Lactante , Recién Nacido , Medición de Riesgo , Sociedades Médicas , Heridas y Lesiones/terapiaRESUMEN
BACKGROUND: No prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI). METHODS: A planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors <48â¯h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure. RESULTS: Of 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AORâ¯=â¯7.6 [pâ¯<â¯0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AORâ¯=â¯11.4 [pâ¯=â¯0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12â¯h after injury. Vasopressor administration at any time was not associated with NOM failure. CONCLUSION: After propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM. LEVEL OF EVIDENCE: Level III prognostic and epidemiological, prospective.
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Bazo , Heridas no Penetrantes , Niño , Humanos , Hígado/lesiones , Estudios Prospectivos , Estudios Retrospectivos , Bazo/lesiones , Centros Traumatológicos , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/tratamiento farmacológicoRESUMEN
BACKGROUND: Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5â¯years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT. METHODS: A single-institution, retrospective review of suspected AHT patients ≤5â¯years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity. RESULTS: Forensic evaluations of 783 children age ≤5â¯years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(ß)â¯=â¯9.9[pâ¯=â¯0.001]), bruising (Expßâ¯=â¯5.7[pâ¯<â¯0.001]), subdural blood (Exp(ß)â¯=â¯5.3[pâ¯=â¯0.001]), seizures (Exp(ß)â¯=â¯4.9[pâ¯=â¯0.02]), lethargy/unresponsiveness (Exp(ß)â¯=â¯2.24[pâ¯=â¯0.02]), loss of consciousness (Exp(ß)â¯=â¯4.69[pâ¯=â¯0.001]), and unknown mechanism of injury (Exp(ß)â¯=â¯3.9[pâ¯=â¯0.001]); skull fracture reduced the risk of AHT by half (Exp(ß)â¯=â¯0.5[pâ¯=â¯0.011]). Social risks factors included prior police involvement (Exp(ß)â¯=â¯5.9[pâ¯=â¯0.001]), substance abuse (Exp(ß)â¯=â¯5.7[pâ¯=â¯.001]), unknown number of adults in the home (Exp(ß)â¯=â¯4.1[pâ¯=â¯0.001]) and intimate partner violence (Exp(ß)â¯=â¯2.3[pâ¯=â¯0.02]). ROC area under the curve (AUC)â¯=â¯0.90([95% CIâ¯=â¯0.86-0.93] pâ¯=â¯.001) provides 73% sensitivity; 91% specificity. CONCLUSIONS: To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT. STUDY TYPE/LEVEL OF EVIDENCE: Prognostic, Level III.
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Maltrato a los Niños , Traumatismos Craneocerebrales , Niño , Maltrato a los Niños/diagnóstico , Preescolar , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/epidemiología , Traumatismos Craneocerebrales/etiología , Femenino , Humanos , Lactante , Masculino , Estudios Prospectivos , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Helmets are effective in reducing traumatic brain injury. However, population effects of helmet laws have not been well described. This study assesses the impact of helmet laws on the motorcycle (MC) fatality rate in the United States from 1999 to 2015. METHODS: Fatality Analysis Reporting System MC fatalities (aged ≥16 years), crash characteristics, and MC-related laws were collected by year for all 50 states from 1999 to 2015 to create a pooled time series. Generalized linear autoregressive modeling was applied to assess the relative contribution of helmet laws to the MC fatality rate while controlling for other major driver laws and crash characteristics. RESULTS: Universal helmet laws were associated with a 36% to 45% decline in the motorcycle crash mortality rate during the study period across all age cohorts (unstandardized regression coefficients are reported): 16 to 20 years, B = -0.45 (p < 0.05); 21 to 55 years, B = -0.42 (p < 0.001); 56 to 65 years, B = -0.38 (p < 0.04); and older than 65 years, B = -0.36 (p < 0.02). Partial helmet laws were associated with a 1% to 81% increase in the fatality rate compared with states with no helmet laws and a 22% to 45% increase compared with universal laws. Helmet usage did not attenuate the countervailing effect of weaker partial laws for 16 to 20 years (B = 0.01 [p < 0.001]). Other laws associated with a declining motorcycle crash mortality rate included the following: social host/overservice laws, 21 to 55 years (B = -0.38 [p < 0.001]); 56 to 65 years (B = -0.16 [p < 0.002]), and older than 65 years (B = -0.12 [p < 0.003]); laws reducing allowable blood alcohol content, 21 to 55 years (B = -4.9 [p < 0.02]); and laws limiting passengers for new drivers 16 to 20 years (B = -0.06 [p < 0.01]). CONCLUSION: During the period of the study, universal helmet laws were associated with a declining mortality rate, while partial helmet laws were associated with an increasing mortality rate. Other state driver laws were also associated with a declining rate. In addition to universal helmet laws, advocating for strict alcohol control legislation and reevaluation of licenses in older riders could also result in significant reduction in MC-related mortality. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.
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Accidentes de Tránsito/mortalidad , Lesiones Traumáticas del Encéfalo/mortalidad , Dispositivos de Protección de la Cabeza , Motocicletas/legislación & jurisprudencia , Adolescente , Adulto , Anciano , Lesiones Traumáticas del Encéfalo/etiología , Lesiones Traumáticas del Encéfalo/prevención & control , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Motocicletas/estadística & datos numéricos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Motor vehicle crash (MVC) fatalities have been declining while states passed various legislation targeting driver behaviors. This study assesses the impact of state laws on MVC fatality rates to determine which laws were effective. METHODS: Publically available data were collected on driver-related motor vehicle laws, law strengths, enactment years, and numbers of verified-trauma centers. Prospective data on crash characteristics and MVC fatalities 16 years or older from Fatality Analysis Reporting System 1999 to 2015 (n = 850) were obtained. Generalize Linear Autoregressive Modeling was used to assess the relative contribution of state laws to the crude MVC fatality rate while controlling for other factors. RESULTS: Lowering the minimum blood alcohol content (BAC) was associated with largest declines for all ages, especially the older cohorts: 16 years to 20 years (B = 0.23; p < 0.001), 21 years to 55 years (B = 1.7; p < 0.001); 56 years to 65 years (B = 3.2; p < 0.001); older than 65 years (B = 4.1; p < 0.001). Other driving under the influence laws were also significant. Per se BAC laws accompanying a reduced BAC further contributed to declines in crude fatality rates: 21 years to 55 years (B = -0.13; p < 0.001); older than 65 years (B = -0.17; p < 0.05). Driving under the influence laws enhancing the penalties, making revocation automatic, or targeting social hosts had mixed effects by age. Increased enforcement, mandatory education, vehicle impoundment, interlock devices, and underage alcohol laws showed no association with declining mortality rates. Red light camera and seatbelt laws were associated with declines in mortality rates for all ages except for older than 65 years cohort, but speed camera laws had no effect. Graduated Driver License laws were associated with declines for 16 years to 21 years (B = -0.06; p < 0.001) only. Laws targeting specific risks (elderly, motorcycles, marijuana) showed no effect on declining MVC mortality rates during the study period. CONCLUSION: States have passed a wide variety of laws with varying effectiveness. A few key laws, specifically laws lowering allowable BAC, implementing red light cameras, and mandating seatbelt use significantly reduced MVC mortality rates from 1999 to 2015. Simply adding more laws/penalties may not equate directly to lives saved. Continued research on state laws will better inform policy makers to meet evolving public health needs in the management of MVC fatalities. LEVEL OF EVIDENCE: Epidemiological, Level III.
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Accidentes de Tránsito/mortalidad , Conducción de Automóvil/legislación & jurisprudencia , Conducir bajo la Influencia/legislación & jurisprudencia , Vehículos a Motor/legislación & jurisprudencia , Cinturones de Seguridad/legislación & jurisprudencia , Accidentes de Tránsito/prevención & control , Adolescente , Adulto , Anciano , Conducción de Automóvil/estadística & datos numéricos , Nivel de Alcohol en Sangre , Conducir bajo la Influencia/estadística & datos numéricos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Vehículos a Motor/estadística & datos numéricos , Estudios Prospectivos , Cinturones de Seguridad/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Estados Unidos/epidemiología , Adulto JovenRESUMEN
BACKGROUND: Many children evaluated for child abuse have non-inflicted injuries due to supervisory neglect. Despite its prevalence, supervisory neglect has received minimal attention. METHODS: We performed a retrospective review of patients maintained in a hospital forensic registry. Text analytics software was used to classify types of supervisory neglect from reported mechanism of injury (MOI). Logistic regression was used to assess risks associated with supervisory neglect. RESULTS: For 1185 eligible patients, 553 were classified as having unintentional injuries. Text analysis identified four types of supervisory neglect for falls (Nâ¯=â¯376): interrupted supervision (53.4%); failure to adapt the home (26.7%); safety equipment non-compliance (12.8%); inadequate substitute care (7.0%); a fifth category was identified for non-falls (Nâ¯=â¯54): rough handling (32.0%). Supervisory neglect was associated with MOI consistent with the injury (AORâ¯=â¯15.5[pâ¯<â¯0.001]), no loss of consciousness (AORâ¯=â¯6.8(pâ¯<â¯0.001]), no bruising away from the injury site (AORâ¯=â¯3.7[pâ¯<â¯0.001]), and direct hospital presentation (AORâ¯=â¯1.8[pâ¯<â¯0.05]). Of the 553 with unintentional injury, 62% had isolated head injuries; 20%, however, had evidence of prior head trauma. CONCLUSIONS: Interrupted supervision was the most common form of supervisory neglect. Twenty percent of forensics patients with head injury found to have non-inflicted injuries had evidence of prior head injury. Supervisory neglect suggests a high-risk population. LEVEL OF EVIDENCE: Level II, Prognosis.
Asunto(s)
Lesiones Accidentales/diagnóstico , Maltrato a los Niños/diagnóstico , Heridas y Lesiones/clasificación , Accidentes por Caídas , Niño , Traumatismos Craneocerebrales , Humanos , Estudios RetrospectivosRESUMEN
BACKGROUND: After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury +2 in weeks. This study evaluates activity restriction adherence and 60â¯day outcomes. METHODS: Non-parametric tests and logistic regression were utilized to assess difference between adherent and non-adherent patients from a 3-year prospective study of NOM for BLSI (≤18â¯years). RESULTS: Of 1007 children with BLSI, 366 patients (44.1%) met the inclusion criteria of a completed 60â¯day follow-up; 170 (46.4%) had liver injury, 159 (43.4%) had spleen injury and 37 (10.1%) had both. Adherence to recommended activity restriction was claimed by 279 (76.3%) patients; 49 (13.4%) reported non-adherence and 38 (10.4%) patients had unknown adherence. For 279 patients who adhered to activity restrictions, unplanned return to the emergency department (ED) was noted for 35 (12.5%) with 16 (5.7%) readmitted; 202 (72.4%) returned to normal activity by 60â¯days. No patient bled after discharge. There was no statistical difference between adherent patients (nâ¯=â¯279) and non-adherent (nâ¯=â¯49) for return to ED (χ2â¯=â¯0.8 [pâ¯<â¯0.4]) or readmission (χ2â¯=â¯3.0 [pâ¯<â¯0.09]); for 216 high injury grade patients, there was no difference between adherent (nâ¯=â¯164) and non-adherent (nâ¯=â¯30) patients for return to ED (χ2â¯=â¯0.6 [pâ¯<â¯0.4]) or readmission (χ2â¯=â¯1.7 [pâ¯<â¯0.2]). CONCLUSION: For children with BLSI, there was no difference in frequencies of bleeding or ED re-evaluation between patients adherent or non-adherent to the APSA activity restriction guideline. LEVEL OF EVIDENCE: Level II, Prognosis.
Asunto(s)
Guías como Asunto , Hígado/lesiones , Cooperación del Paciente/estadística & datos numéricos , Bazo/lesiones , Heridas no Penetrantes/terapia , Adolescente , Niño , Servicio de Urgencia en Hospital/estadística & datos numéricos , Ejercicio Físico , Femenino , Estudios de Seguimiento , Humanos , Masculino , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: Motor vehicle crashes are a leading cause of adolescent death from trauma. A recent study found American College of Surgeons-verified pediatric trauma centers (vPTC) were inversely correlated with pediatric mortality, but the analysis was limited to a single year. This study assesses the contribution of vPTCs, crash characteristics, and state driver laws on 15- to 17-year-old motor vehicle crash mortality for all 50 states from 1999 to 2015. METHODS: Prospective data on motor vehicle fatalities, crash characteristics, state driving laws, and American College of Surgeons-verified trauma centers were collected from publicly available sources for 50 US states from 1999 to 2015. A mixed fixed/random effects multivariate regression model was fitted to assess the relative contribution of crash characteristics, state laws, and vPTCs while controlling for state variation and time trends. RESULTS: The final regression model included driver and crash characteristics, verified trauma centers, and state laws. Camera laws ([B = -0.57 [p < 0.001]) were associated with a 57% decrease in the rate of change in adolescent crude fatalities. The lagged Level 1 vPTC crude rate (B = -0.12 [p < .001]) was protective and contributed independently to a 12% decline in the rate of change in teen fatalities over the time period. Seat belt laws (B = -0.15 [p < 0.001]), graduated driver's license passenger restrictions (B = -0.07[p < 0.001]), graduated driver's license learner permit period (B = -0.04 [p < 0.002]), nondeployed airbag (B = -0.003 [p < 0.001]), and Hispanic heritage (B = -0.003 [p < 0.05]) were protective. Increased risk of fatality was associated with minivan (B = 0.01 [p < 0.001]), speed > 90 mph (B = 0.004 [p < 0.001]), rural roads (B = 0.002 [p < 0.002], unknown seat belt compliance (B = 0.004 [p < 0.001]), and dry road surface (B = 0.005 [p < 0.001]). CONCLUSIONS: State camera laws during the study time frame are associated with a 57% decrease in the rate of change in adolescent crude fatalities; vPTCs during the study time period reduced overall rate of change in the crude fatality rate by 12%. State laws, restrictions on teenage passengers and longer learner's permit periods, and seat belt laws are associated with significant decreases in the crude teen mortality rate. LEVEL OF EVIDENCE: Prospective study and prevention, level III.
Asunto(s)
Accidentes de Tránsito/mortalidad , Conducción de Automóvil/legislación & jurisprudencia , Pediatría , Centros Traumatológicos , Adolescente , Airbags , Automóviles , Femenino , Hispánicos o Latinos/estadística & datos numéricos , Humanos , Concesión de Licencias/legislación & jurisprudencia , Masculino , Mortalidad/etnología , Mortalidad/tendencias , Factores Protectores , Factores de Riesgo , Cinturones de Seguridad/legislación & jurisprudencia , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: One of the concerns associated with nonoperative management of splenic injury in children has been delayed splenic bleed (DSB) after a period of hemostasis. This study evaluates the incidence of DSB from a multicenter 3-year prospective study of blunt splenic injuries (BSI). METHODS: A 3-year prospective study was done to evaluate nonoperative management of pediatric (≤18years) BSI presenting to one of 10 pediatric trauma centers. Patients were tracked at 14 and 60days. Descriptive statistics were used to summarize patient and injury characteristics. RESULTS: During the study period, 508 children presented with BSI. Median age was 11.6 [IQR: 7.0, 14.8]; median splenic injury grade was 3 [IQR: 2, 4]. Nonoperative management was successful in 466 (92%) with 18 (3.5%) patients undergoing splenectomy at the index admission, all within 3h of injury. No patient developed a delayed splenic bleed. At least one follow-up visit was available for 372 (73%) patients. CONCLUSION: A prior single institution study suggested that the incidence of DSB was 0.33%. Based on our results, we believe that the rate may be less than 0.2%. LEVEL OF EVIDENCE: Level II, Prognosis.