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BACKGROUND: Option B+ has increased the number of pregnant women initiating antiretroviral therapy for HIV, yet retention in HIV care is sub-optimal. Retention may be affected by antenatal depression. However, few data exist on antenatal depression in this population. AIM: Describe the prevalence and factors associated with antenatal depression among Malawian women enrolled in Option B+. METHOD: At their first antenatal visit, women with HIV provided demographic and psychosocial information, including depression as measured with the locally validated Edinburgh Postnatal Depression Scale (EPDS). Prevalence ratios (PR) for factors associated with probable depression (EPDS ≥6) were estimated with log binomial regression. RESULTS: 9.5% (95% CI: 7.5-11.9%) of women screened positive for current depression, and 46% self-reported a history of depression or anxiety. Women were more likely to screen positive for current depression if they reported a history of depression (adjusted PR: 2.42; 95% CI: 1.48-3.95) or had ever experienced intimate partner violence (1.77; 1.11-2.81). Having an unintended current pregnancy (1.78; 0.99-3.21), being unmarried (1.66; 0.97-2.84), or employed (1.56; 1.00-2.44) had potential associations with probable depression. CONCLUSIONS: Probable antenatal depression affected a notable proportion of women living with HIV, comparable to other global regions. Screening for antenatal depression in HIV care should be considered.
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Depressão/epidemiologia , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Complicações na Gravidez/epidemiologia , Adulto , Estudos Transversais , Depressão/complicações , Feminino , Infecções por HIV/complicações , Humanos , Malaui , Gravidez , Cuidado Pré-Natal , Prevalência , Escalas de Graduação Psiquiátrica , Adulto JovemRESUMO
Importance: Extreme weather has major implications for state and national health care systems; however, statistics examining weather-related injuries and fatalities are limited. Objective: To examine the frequency and regional distribution of major disaster events (MDEs) in the US. Design, Setting, and Participants: This ecologic cross-sectional study of MDEs occurring between January 1, 2006, and December 31, 2021, evaluated US data on all injuries and fatalities included in the National Oceanic and Atmospheric Administration National Centers for Environmental Information Storm Events Database. The data analysis was performed between February 22, 2023, and April 1, 2024. Exposures: Major disaster events defined as an environmental event that caused either at least 50 injuries or at least 10 deaths. Main Outcomes and Measures: All MDEs were evaluated using descriptive statistics for event type, property damage, and rural or urban classification according to the National Centers for Health Statistics Urban-Rural Classification Scheme for Counties. The location of events according to Administration for Strategic Preparedness and Response (ASPR) region and hospital bed capacity of ASPR regions were also examined. Results: Between 2006 and 2021, 11â¯159 storm events caused 42â¯254 injuries and 9760 deaths. Major disaster events accounted for 209 weather events (1.9%) but caused 19â¯463 weather-associated injuries (46.1%) and 2189 weather-associated deaths (22.4%). The majority of MDEs were caused by extreme heat (86 [41.1%]) and tornadoes (67 [32.1%]). While a larger proportion of MDEs occurred in urban areas (151 [75.1%]) vs rural areas (50 [24.9%]), rural MDEs caused a median of 9 (IQR, 2-16) deaths per event vs 4 (IQR, 0-14) deaths per event in urban areas. The majority of MDEs occurred in either ASPR region 4 (51 [24.5%]) or region 9 (45 [21.6%]). Certain event types, such as fires, wind, and hurricanes or storms, were geographically concentrated, while extreme heat and floods affected regions across the US equally. Urban counties had disproportionately greater hospital bed capacity than rural counties relative to population and MDE distributions. Conclusions and Relevance: The findings of this ecologic study indicate that while MDEs accounted for a small proportion of all weather events, they were associated with a disproportionate number of injuries and fatalities. Integrating these data into county, state, and regional hazard vulnerability analyses is crucial to ensuring preparedness and mitigating climate risk.
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Clima Extremo , Humanos , Estudos Transversais , Estados Unidos/epidemiologia , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/epidemiologia , Desastres/estatística & dados numéricosRESUMO
BACKGROUND: Trauma recidivism is associated with future trauma-associated morbidity and mortality. Previous evidence suggests that socioeconomic factors predict trauma recidivism in older children (10-18 years); however, risk factors in US children 10 years and younger have not been studied. We sought to determine the factors associated with trauma recidivism in young children 10 years and younger. METHODS: We conducted a retrospective cohort study of pediatric trauma patients 10 years and younger who presented to a single American College of Surgeons-verified Level I pediatric trauma center from July 1, 2017, to June 30, 2021. All patients were evaluated for prior injury during trauma registry entry. Characteristics at the index injury were collected via chart review. Patients were geocoded to assess Social Vulnerability Index. Logistic regression examined factors associated with recidivism. Best subset selection was used to compare multivariable models and identify the most predictive and parsimonious model. Statistical significance was set at p < 0.05. RESULTS: Of the 3,518 patients who presented in the study period, 169 (4.8%) experienced a prior injury. Seventy-six percent (n = 128) had one prior injury presentation, 18% (n = 31) had two prior presentations, and 5.9% (n = 10) had three or more. Falls were the most common mechanism in recidivists (63% vs. 52%, p = 0.009). Child physical abuse occurred in 6.5% of patients, and 0.9% experienced penetrating injury. The majority (n = 137 [83%]) were discharged home from the emergency department. There was no significant difference in the frequency of penetrating injury and child physical abuse between recidivists and nonrecidivists. Following logistic regression, the most parsimonious model demonstrated that recidivism was associated with comorbidities, age, falls, injury location, nontransfer, and racialization. No significant associations were found with Social Vulnerability Index and insurance status. CONCLUSION: Medical comorbidities, young age, injury location, and falls were primarily associated with trauma recidivism. Support for parents of young children and those with special health care needs through injury prevention programs could reduce trauma recidivism in this population. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.
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Centros de Traumatologia , Ferimentos e Lesões , Humanos , Criança , Masculino , Feminino , Estudos Retrospectivos , Pré-Escolar , Fatores de Risco , Ferimentos e Lesões/epidemiologia , Ferimentos e Lesões/etiologia , Lactente , Centros de Traumatologia/estatística & dados numéricos , Fatores Socioeconômicos , Sistema de Registros , Estados Unidos/epidemiologia , Relesões/epidemiologia , Escala de Gravidade do FerimentoRESUMO
BACKGROUND: Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in non-pediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement. METHODS: The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) the same calendar year. Center characteristics and pediatric (0-15y) volume from the NTDB were linked to weighted pediatric readiness scores (wPRS) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics. RESULTS: The wPRS was reported for 77% (749/973) of centers that contributed to the NTDB. ED Pediatric Readiness was highest in ACS level one pediatric trauma centers (PTCs), but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included ACS level one PTC verification, pediatric trauma volume, and the presence of a PICU. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives. CONCLUSION: ED pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at non-pediatric centers are needed, particularly in centers that routinely transfer children out. LEVEL OF EVIDENCE: Epidemiologic, Level III.
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Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.
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COVID-19 , Oxigenação por Membrana Extracorpórea , Humanos , Criança , Feminino , Pré-Escolar , Adolescente , Masculino , Oxigenação por Membrana Extracorpórea/efeitos adversos , COVID-19/terapia , Estudos Retrospectivos , Hospitalização , Mortalidade HospitalarRESUMO
BACKGROUND: Firearm injury is now the leading cause of death for children in the United States. Functional morbidity among survivors also contributes to the public health burden of firearm injury but has not been quantified in children. This study aimed to assess functional impairment among survivors of pediatric firearm injury. METHODS: We analyzed an 8-year (2014-2022) retrospective cohort of children (0-18 years) treated for firearm injuries at 2 urban level 1 pediatric trauma centers. The Functional Status Scale was used to assess functional impairment among survivors at discharge and at follow-up. Functional impairment was defined using multisystem (Functional Status Scale ≥8) and single-system (Functional Status Scale = 7) definitions. RESULTS: The cohort included 282 children with a mean age of 11.1 (standard deviation 4.5) years. In-hospital mortality was 7% (n = 19). Functional impairment (Functional Status Scale ≥8) was present in 9% (n = 24) of children at discharge and in 7% (n = 13/192) at follow-up. Mild impairment in a single domain (Functional Status Scale = 7) was seen in 42% (n = 110) of the cohort at discharge. This impairment persisted to follow-up in most (67%, n = 59/88) of these children. CONCLUSION: Functional impairment at discharge after firearm injury is common among children surviving transport in these trauma centers. These data highlight the added value of non-mortality metrics in assessing the health burden of pediatric firearm injuries. The collective impact of mortality and functional morbidity should be considered when advocating for resources to protect children.
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Armas de Fogo , Ferimentos por Arma de Fogo , Criança , Humanos , Estados Unidos , Ferimentos por Arma de Fogo/epidemiologia , Estudos Retrospectivos , Alta do Paciente , Centros de TraumatologiaRESUMO
BACKGROUND: Functional impairment has been proposed as an alternative outcome for quality improvement in pediatric trauma. The functional status scale (FSS) has been used in studies of injured children, but has only been validated with resource-intensive in-person assessment. Implementation with retrospective chart-based FSS assessment would offer a simplified and scalable alternative. The purpose of this study was to evaluate interrater reliability of retrospective FSS assessment and to identify factors associated with unreliable assessment. METHODS: A retrospective cohort of admissions to a Level I pediatric trauma center between July 2020 and June 2021 was analyzed. Two physicians and two nurse registrars reviewed charts to obtain measures of six FSS domains (mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status) at discharge. Functional impairment was categorized by total FSS scores as good (6,7), mild impairment (8,9), moderate impairment (10-15), severe impairment (16-21), or very severe impairment (>21). Interrater reliability was assessed using intraclass correlation (ICC). Predictors of rater disagreement were evaluated using multivariable logistic regression. RESULTS: The cohort included 443 children with a mean age of 7.4 years (standard deviation, 5.4 years) and median Injury Severity Score of 9 (interquartile range, 5-12). The median time per chart to assess FSS was 2 minutes (interquartile range, 1-2). Thirty-seven patients (8%) had functional impairment at discharge. Interrater reliability was excellent for total FSS score (ICC = 0.87) and good for FSS impairment categorization (ICC = 0.80). Rater disagreement of functional impairment categorization occurred in 14% of cases overall. Higher level of functional impairment and use of therapies (occupational and speech language therapy) were independently associated with more frequent rater disagreement. CONCLUSION: Chart-based FSS assessment is feasible and reliable, but may require more detailed review for patients with higher level of impairment that require allied health therapy. Validation of chart-based assessment is needed before widespread implementation. LEVEL OF EVIDENCE: Prognostic/Epidemiological, Level III.
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Estado Funcional , Alta do Paciente , Humanos , Criança , Reprodutibilidade dos Testes , Estudos Retrospectivos , ComunicaçãoRESUMO
BACKGROUND: Quality improvement efforts within pediatric trauma centers (PTCs) are robust, but the majority of children do not receive initial postinjury care at PTCs. Disparities in access to quality trauma care remain, particularly for children who initially access the trauma system outside of a PTC. The purpose of this project was to identify unmet needs for injured children within the pediatric emergency care system and to determine national priorities for quality improvement across the continuum of pediatric trauma care. METHODS: A panel of delegates representing patients and families, prehospital providers, federal funding partners, nurses, and physicians was recruited from 10 national stakeholder organizations. Potential targets were identified using an initial stakeholder meeting followed by a free text response survey. Free text items were coded and condensed as themes and then ranked by the panel using a modified Delphi approach to determine consensus priorities. Items not achieving >35% prioritization on a given iteration were dropped from subsequent iterations. Consensus was defined as 75% of members designating an item as a top-four priority. RESULTS: Nineteen themes were identified as potential targets for QI initiatives. Four iterations of panel ranking were used to achieve consensus, with four priorities identified: (1) creation of a toolkit and standard provider training for pediatric trauma triage, shock recognition, and early recognition for need to transfer to higher level of care; (2) development of minimum standards for pediatric trauma resuscitation and stabilization capability in nonpediatric centers; (3) facilitating creation of local nursing and physician champions for pediatric trauma; and (4) development and dissemination of best-practice guidelines to improve imaging practices for injured children. CONCLUSION: System-level quality improvement priorities for pediatric trauma care should focus resources on developing and implementing minimum pediatric standards for injury care, frontline provider training, stabilization protocols, imaging guidelines, and local pediatric champions. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.
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Serviços Médicos de Emergência , Melhoria de Qualidade , Criança , Consenso , Técnica Delphi , Humanos , TriagemRESUMO
The annual incidence of mild traumatic brain injury (MTBI) is 3.8 million in the USA with 10â»15% experiencing persistent morbidity beyond one year. Chronic traumatic encephalopathy (CTE), a neurodegenerative disease characterized by accumulation of hyperphosphorylated tau, can occur with repetitive MTBI. Risk factors for CTE are challenging to identify because injury mechanisms of MTBI are heterogeneous, clinical manifestations and management vary, and CTE is a postmortem diagnosis, making prospective studies difficult. There is growing interest in the genetic influence on head trauma and development of CTE. Apolipoprotein epsilon 4 (APOE-ε4) associates with many neurologic diseases, and consensus on the ε4 allele as a risk factor is lacking. This review investigates the influence of APOE-ε4 on MTBI and CTE. A comprehensive PubMed literature search (1966 to 12 June 2018) identified 24 unique reports on the topic (19 MTBI studies: 8 athletic, 5 military, 6 population-based; 5 CTE studies: 4 athletic and military, 1 leucotomy group). APOE-ε4 genotype is found to associate with outcomes in 4/8 athletic reports, 3/5 military reports, and 5/6 population-based reports following MTBI. Evidence on the association between APOE-ε4 and CTE from case series is equivocal. Refining modalities to aid CTE diagnosis in larger samples is needed in MTBI.