American Indian and Non-Hispanic White Midlife Mortality Is Associated With Medicaid Spending: An Oklahoma Ecological Study (1999-2016).

Objective: A one third reduction of premature deaths from non-communicable diseases by 2030 is a target of the United Nations Sustainable Development Goal for Health. Unlike in other developed nations, premature mortality in the United States (US) is increasing. The state of Oklahoma suffers some of the greatest rates in the US of both all-cause mortality and overdose deaths. Medicaid opioids are associated with overdose death at the patient level, but the impact of this exposure on population all-cause mortality is unknown. The objective of this study was to look for an association between Medicaid spending, as proxy measure for Medicaid opioid exposure, and all-cause mortality rates in the 45-54-year-old American Indian/Alaska Native (AI/AN45-54) and non-Hispanic white (NHW45-54) populations. Methods: All-cause mortality rates were collected from the US Centers for Disease Control & Prevention Wonder Detailed Mortality database. Annual per capita (APC) Medicaid spending, and APC Medicare opioid claims, smoking, obesity, and poverty data were also collected from existing databases. County-level multiple linear regression (MLR) analyses were performed. American Indian mortality misclassification at death is known to be common, and sparse populations are present in certain counties; therefore, the two populations were examined as a combined population (AI/NHW45-54), with results being compared to NHW45-54 alone. Results: State-level simple linear regressions of AI/NHW45-54 mortality and APC Medicaid spending show strong, linear correlations: females, coefficient 0.168, (R2 0.956; P < 0.0001; CI95 0.15, 0.19); and males, coefficient 0.139 (R2 0.746; P < 0.0001; CI95 0.10, 0.18). County-level regression models reveal that AI/NHW45-54 mortality is strongly associated with APC Medicaid spending, adjusting for Medicare opioid claims, smoking, obesity, and poverty. In females: [R2 0.545; (F)P < 0.0001; Medicaid spending coefficient 0.137; P < 0.004; 95% CI 0.05, 0.23]. In males: [R2 0.719; (F)P < 0.0001; Medicaid spending coefficient 0.330; P < 0.001; 95% CI 0.21, 0.45]. Conclusions: In Oklahoma, per capita Medicaid spending is a very strong risk factor for all-cause mortality in the combined AI/NHW45-54 population, after controlling for Medicare opioid claims, smoking, obesity, and poverty.

Prescription Opioids Are Associated With Population Mortality in US Deep South Middle-Age Non-hispanic Whites: An Ecological Time Series Study.

Objective: The US Burden of Disease Collaborators reported that between 1990 and 2016, the top 10 states with increasing probability of death between the ages of 20 and 55 years were all in the South. A recent study of annual surveillance data found that increasing all-cause mortality rates were occurring in middle-age non-Hispanic whites. The vast proportion of all-cause mortality consists of medical causes, not external causes (i.e., overdose, mental illness, suicide, homicide, or motor vehicle crashes). It has been hypothesized by researchers that the ongoing opioid epidemic has an etiologic role in the trend of increasing medical death, but ecological studies looking for an association have not been published. The objective of this study was to test the hypothesis that hydrocodone and oxycodone sales are temporally associated and correlated with annual NHW45-54 medical-cause mortality rates in the Deep South region comprised of Alabama, Arkansas, Louisiana, Mississippi, Oklahoma, and South Carolina. Methods: Mortality and opioid sales data were obtained from the Centers for Disease Control and Prevention Wonder Detailed Mortality and University of Wisconsin State Health Access Data Assistance Center databases, respectively. Annual, state and regional NHW45-54 medical-cause mortality and opioid sales data were analyzed using Spearman rank correlation (rs) testing, after first and second differencing, in order to achieve stationarity and control for trend similarities. Results: Sales of prescription opioids follow very similar temporal patterns across these six states, with simultaneous increases in 2007 and 2013. With few exceptions, annual opioids sales trends were correlated state-to-state. Two prominent spikes are evident in the aggregated opioid sales trends of the six states, with both sales spikes preceding same-directional fluctuations in medical-cause mortality by ~1 year. After a 1 year adjustment of second-differenced data, population hydrocodone exposure was correlated with female NHW45-54 population medical-cause mortality [rs(13) = 0.540; P = 0.038]; and oxycodone exposure correlated with male NHW45-54 population medical-cause mortality [rs(13) = 0.607; P = 0.016]. Conclusions: State sales of prescription hydrocodone and oxycodone in the six states studied follow non-random, systematic trajectories. A strong correlation and temporal association exists between prescription opioid sales and medical-cause mortality in this Deep South NHW45-54 population.

All-terrain vehicle crash factors and associated injuries in patients presenting to a regional trauma center.

BACKGROUND: It is widely accepted that all-terrain vehicles (ATVs) can be dangerous to operators. Understanding the mechanisms of ATV crashes, especially rollovers, can provide important insight to consumers, legislators, and manufacturers on ATV safety and protection of the users. METHODS: From March 1, 2003 to July 31, 2005, all patients with ATV-related injuries presenting to a regional trauma center were enrolled in an ATV crash data bank. Data were collected on the patients and the circumstances surrounding each crash. RESULTS: A total of 193 persons were treated during the study period for ATV-related injuries. Among the 190 nonfatally injured patients, almost half (47%) were diagnosed with a head injury. In 63% of crashes the ATV rolled over. The direction of the rollover was strongly associated with the type of riding terrain or slope. ATVs traveling on flat or uneven surfaces were strongly associated with right-side rollovers (odds ratio [OR] = 32.9, 95% confidence interval [CI] = 6.6-221.5). ATVs traveling uphill were strongly associated with backward rollovers (OR = 173.6, 95% CI = 27.2-1,497.0). Children had a significantly greater risk compared with adults of right-side rollovers on flat and uneven surfaces (OR = 4.7, 95% CI = 1.2-17.5) Adults were more likely to be injured in rollover crashes where the ATV was traveling uphill; in all of these cases the vehicle rolled backwards. CONCLUSIONS: These findings suggest that nonrandom, modifiable factors are likely involved. Our data provide unique insight into specific mechanisms of ATV crashes, particularly rollovers, and those involving children. Findings may be applicable to changes in ATV design and education of users.

Operation Child-ID: reunifying children with their legal guardians after Hurricane Katrina.

Children constitute a vulnerable population and special considerations are necessary in order to provide proper care for them during disasters. After disasters such as Hurricane Katrina, the rapid identification and protection of separated children and their reunification with legal guardians is necessary in order to minimise secondary injuries (i.e. physical and sexual abuse, neglect and abduction). At Camp Gruber, an Oklahoma shelter for Louisianans displaced by Hurricane Katrina, a survey tool was used to identify children separated from their guardians. Of the 254 children at the camp, 36 (14.2 per cent) were separated from their legal guardians. Answering 'no' to the question of whether the accompanying adult was the guardian of the child prior to Hurricane Katrina was a strong predictor (27.8 per cent versus 3.2 per cent) of being listed as 'missing' by the National Center for Missing and Exploited Children (NCMEC). All the children at Camp Gruber who were listed as 'missing' by the NCMEC were subsequently reunited with their guardians.

Pediatric disaster response in developed countries: ten guiding principles.

Mass casualty incidents and large-scale disasters involving children are likely to overwhelm a regional disaster response system. Children have unique vulnerabilities that require special considerations when developing pediatric response systems. Although medical and trauma strategies exist for the evaluation and treatment of children on a daily basis, the application of these strategies under conditions of resource-constrained triage and treatment have rarely been evaluated. A recent report, however, by the Institute of Medicine did conclude that on a day-to-day basis the U.S. healthcare system does not adequately provide emergency medical services for children. The variability, scale, and uncertainty of disasters call for a set of guiding principles rather than rigid protocols when developing pediatric response plans. The authors propose the following guiding principles in addressing the well-recognized, unique vulnerabilities of children: (1) terrorism prevention and preparedness, (2) all-hazards preparedness, (3) postdisaster disease and injury prevention, (4) nutrition and hydration, (5) equipment and supplies, (6) pharmacology, (7) mental health, (8) identification and reunification of displaced children, (9) day care and school, and (10) perinatology. It is hoped that the 10 guiding principles discussed in this article will serve as a basic framework for developing pediatric response plans and teams in developed countries.

"Operation Child-Safe": a strategy for preventing unintentional pediatric injuries at a Hurricane Katrina evacuee shelter.

INTRODUCTION: Children represent a vulnerable population, and special considerations are necessary to care for them properly during disasters. Comprehensive disaster responses include addressing the unique needs of children during mass-casualty incidents, such as the prevention of unintentional injuries. Early in the morning of 04 September 2005, approximately 1,600 Hurricane Katrina and/or flood survivors from New Orleans, including approximately 300 children, arrived at Camp Gruber, an Oklahoma National Guard base in Eastern Oklahoma. PROBLEM: The primary function of Camp Gruber to train support personnel for the Oklahoma National Guard. This is not a child-safe environment. It was hypothesized that the camp contained numerous child injury hazards and that these hazards could be removed systematically using local child injury prevention experts, thereby preventing unintentional injuries to the displaced children. METHODS: On 08 September, "Operation Child-Safe" was launched by the Pediatric Injury Response Team to identify and remove pediatric injury hazards from Camp Gruber. Injury prevention experts from the Safe Kids Tulsa Area (SKTA) Chapter, the closest pediatric injury prevention group in the region, spearheaded the operation. Several visits were required to remove all of the injury hazards that were identified. RESULTS: Many hazards were identified and removed immediately, while others were addressed in a formal letter to the Camp Gruber Commander for required consent to implement changes. Hazards identified in the camp included, but were not limited to: (1) dangerous chemicals; (2) choking hazards; (3) open electrical outlets; and (4) missing smoke detectors. Bicycle helmets, car seats, strollers, portable cribs, and other safety-related items were passed out to families in need. A licensed daycare facility also was established in order to give the adult guardians a break from constant supervision. Over the course of one month, only one preventable injury (minor head injury) was reported during camp operations, and this particular injury occurred two days before "Operation Child-Safe" was initiated (Day 3 of camp operations). CONCLUSIONS: In the aftermath of an event that displaces large numbers of people, it is likely that children will be exposed to numerous injury hazards. Volunteers with expertise in child injury prevention are needed to make an evacuee shelter safer for children.

All-terrain vehicle-related central nervous system injuries in Oklahoma.

OBJECTIVE: Determine the statewide, population-based incidence and epidemiology of all-terrain vehicle (ATV)-related severe central nervous system (CNS) injuries in Oklahoma. METHODS: Hospitalized and fatal traumatic brain injuries and spinal cord injuries are reportable conditions in Oklahoma. Professionally trained staff reviewed all medical examiner and hospital medical records. RESULTS: From 1992 through 2002 there were 391 persons hospitalized (n=353) or died (n=38) from an ATV-related neurologic injury (average annual rate 1.1/100,000 population), including 369 traumatic brain injuries and 18 spinal cord injuries and 4 persons with both injuries. These accounted for 1% of total CNS injuries in Oklahoma. Forty-five percent of persons who died were under 16 years of age. An average of 23 ATV-related injuries per year occurred before 1998; the number of cases doubled in 1999 and 2000 (mean=46) and tripled in 2002 and 2003 (mean=69). Rates were highest among males 15-24 (4.1/100,000) and 5-14 (3.8/100,000) and among whites (1.2/100,000). Persons who collided with a stationary or moving object were significantly more likely to suffer a fatal traumatic brain injury than those in non-collision events (OR 3.0, 95% CI 1.4, 6.8). Rollover of the ATV occurred in 38% of ATV incidents, and in 28% of traumatic brain injury fatalities, it occurred without a preceding collision. CONCLUSIONS: ATV use can result in significant neurologic morbidity and mortality, especially among children and young adults. Heightened public awareness and parental education on the dangers of these vehicles is imperative. State legislation restricting the use of ATVs among children under the age of 16 years is recommended. Vehicle design changes such as lowering the center of gravity and installing rollover protective structures should be considered.

Mechanisms of head injury in bull riders with and without the Bull Tough helmet--a case series.

INTRODUCTION: Bull riding is one of the most dangerous sporting activities of the modern era. Head injuries are common in bull riders, yet helmets and faceguards are rarely mandated in competitive bull riding events and few participants use such protective headgear. OBJECTIVE: The purpose of examining this case series was to characterize head and face injuries in bull riders, to gain a better understanding of the mechanisms associated with the various injury types and to assess the effect of wearing the Bull Tough Helmet (BTH). METHODS: A survey was sent to 320 bull riders, asking them to provide details about the head and face injuries they had sustained while bull riding with and without the BTH. Eighty-one (31%) of the 265 surveys that reached their intended athlete were completed and returned. Riders were also asked to describe specific incidents where the BTH had saved them from head injury. RESULTS: Respondents described 84 incidents of injury while not wearing the BTH; 110 injuries resulted. Respondents described 33 incidents of injury while wearing the BTH; 39 injuries resulted. Specific mechanisms and injury types were reported for both cohorts with concussions, lacerations and facial fractures being the most common injury types. In addition, respondents described 170 events in which an injury was prevented by the BTH. CONCLUSIONS: Bull riders are at great risk of suffering severe head and facial injuries. Safe and effective helmets with protective face guards must be worn by bull riders if the incidence of these injuries is to be diminished. Organizations, promoters and schools that sponsor bull riding events, especially for minors, should mandate protective headgear in order to better protect these athletes.

Survey analysis to assess the effectiveness of the bull tough helmet in preventing head injuries in bull riders: a pilot study.

OBJECTIVE: The purpose of this pilot study was to assess the effectiveness of the Bull Tough helmet (Bull Tough, Seguin, TX) in preventing head injuries to bull riders. The hypothesis was that this helmet is effective in diminishing the incidence of head injuries in bull riders. DESIGN: This study was a retrospective study. METHODS: Surveys were mailed to 320 purchasers of the Bull Tough helmet. Participants were asked to recall the numbers of rides performed in 1999 while wearing the helmet and the number of rides performed in 1999 while not wearing the helmet. In addition, they were asked to provide the number and severity of head injuries suffered in 1999 both while wearing the helmet and while not wearing the helmet. SETTING: Participants responding to the survey were bull riders from the United States and Canada. PARTICIPANTS: Eighty-one riders responded to the survey. MAIN OUTCOME MEASUREMENTS: The primary outcome measurements were planned before data collection began and included the incidence of head injuries to bull riders both while wearing the helmet and while not wearing the helmet. RESULTS: While not wearing a helmet, the incidence of head injury was 1.54% per ride (11 head injuries/713 rides). While wearing the helmet, the incidence of head injury was 0.80% per ride (28 head injuries/3,518 rides). Using the X(2) test, the p value was 0.0570. CONCLUSIONS: This study supports the hypothesis that the Bull Tough helmet diminishes the incidence of head injury in bull riders.