A pilot clinical trial of the Screening and Tool for Awareness and Relief of Trauma for survivors of gun violence.

BACKGROUND: Survivors of gun violence have significant sequelae including reinjury with a firearm and mental health disorders that often go undiagnosed and untreated. The Screening and Tool for Awareness and Relief of Trauma (START) is a targeted behavioral mental health intervention developed for patients who come from communities of color with sustained and persistent trauma. METHODS: In this pilot study, we evaluate the feasibility of completing a randomized controlled trial to test the START intervention. Using a mixed methods study design, we used both quantitative and qualitative data collection to assess the START intervention and the feasibility of completing a randomized controlled trial. The purpose of this study was to estimate important study parameters that would enable a future randomized controlled trial. RESULTS: We were able to make conclusions about several crucial domains of a behavioral intervention trial: (1) recruitment and retention-we had a high follow-up rate, but our recruitment was low (34% of eligible participants); (2) acceptability of the intervention-the addition of audiovisual resources would make the tools more accessible; (3) feasibility of the control-more appropriate for a stepped wedge cluster randomized controlled trial design; (4) intervention fidelity-there was an 81% concordance rate between the fidelity survey results and the audio recordings; (5) approximate effect size-there was a 0.4-point decrease in the PTSD Checklist-Civilian Version in the control compared with a 10.7-point decrease in the treatment group for the first month. CONCLUSION: While it was feasible to conduct a randomized controlled trial, our findings suggest that a stepped wedge cluster randomized controlled trial design may be the most successful trial design for the START intervention. In addition, the inclusion of a "credible messenger" to recruit participants into the study and the development of audiovisual resources for START would improve recruitment and effectiveness. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Implementation of an emerging hospital-based violence intervention program: a multimethod study.

Background: Individuals who experience assaultive firearm injury are at elevated risk for violent reinjury and multiple negative physical and psychological health outcomes. Hospital-based violence intervention programs (HVIPs) may improve patient outcomes through intensive, community-based case management. Methods: We conducted a multimethod evaluation of an emerging HVIP at a large trauma center using the RE-AIM framework. We assessed recruitment, violent reinjury outcomes, and service provision from 2020 to 2022. Semistructured, qualitative interviews were performed with HVIP participants and program administrators to elicit experiences with HVIP services. Directed content analysis was used to generate and organize codes from the data. We also conducted clinician surveys to assess awareness and referral patterns. Results: Of the 319 HVIP-eligible individuals who presented with non-fatal assaultive firearm injury, 39 individuals (12%) were enrolled in the HVIP. Inpatient admission was independently associated with HVIP enrollment (OR 2.6, 95% CI 1.3 to 5.2; p=0.01). Facilitators of Reach included engaging with credible messengers, personal relationships with HVIP program administrators, and encouragement from family to enroll. Fear of disclosure to police was cited as a key barrier to enrollment. For the Effectiveness domain, enrollment was not associated with reinjury (OR 0.70, 95% CI 0.16 to 3.1). Participants identified key areas of focus where needs were not met including housing and mental health. Limited awareness of HVIP services was a barrier to Adoption. Participants described strengths of Implementation, highlighting the deep relationships built between clients and administrators. For the long-term Maintenance of the program, both clinicians and HVIP clients reported that there is a need for HVIP services for individuals who experience violent injury. Conclusions: Credible messengers facilitate engagement with potential participants, whereas concerns around police involvement is an important barrier. Inpatient admission provides an opportunity to engage patients and may facilitate recruitment. HVIPs may benefit from increased program intensity. Level of evidence: IV.

The effect of the COVID-19 pandemic on community violence in Connecticut.

INTRODUCTION: Natural disasters may lead to increases in community violence due to broad social disruption, economic hardship, and large-scale morbidity and mortality. The effect of the COVID-19 pandemic on community violence is unknown. METHODS: Using trauma registry data on all violence-related patient presentations in Connecticut from 2018 to 2021, we compared the pattern of violence-related trauma from pre-COVID and COVID pandemic using an interrupted time series linear regression model. RESULTS: There was a 55% increase in violence-related trauma in the COVID period compared with the pre-COVID period (IRR: 1.55; 95%CI: 1.34-1.80; p-value<0.001) driven largely by penetrating injuries. This increase disproportionately impacted Black/Latinx communities (IRR: 1.61; 95%CI: 1.36-1.90; p-value<0.001). CONCLUSION: Violence-related trauma increased during the COVID-19 pandemic. Increased community violence is a significant and underappreciated negative health and social consequence of the COVID-19 pandemic, and one that excessively burdens communities already at increased risk from systemic health and social inequities.

Evaluation of Firearm-Related Reinjury in Connecticut: An Opportunity for Gun Violence Prevention.

BACKGROUND: The regional extent of the risk of repeat firearm-related injury (FRI) and homicide mortality for victims of firearm injury in Connecticut is unknown. In this study, we evaluate the risk of repeat firearm injury in survivors of firearm violence in Connecticut. METHODS: Using medical record data from the Yale New Haven Health (YNHH) system and data from the Connecticut Office of the Chief Medical Examiner, we conducted a cohort study of patients with an FRI in 2014 to determine their risk of a repeat firearm injury or mortality from homicide in the ensuing 5 years compared with nonviolence-related trauma patient controls. RESULTS: We identified 94 patients with an FRI in the YNHH system from 2014 who survived to discharge. Of these patients, 8.5% (8 of 94) had a repeat FRI and 2% (2 of 94) died from homicide within the next 5 years. Compared with nonviolence-related trauma patients from 2014 (n = 2001), those with an FRI had 12 times the odds of a repeat firearm injury (odds ratio: 12.0, P = 0.047) in the next 5 years after adjustment for relevant covariates. CONCLUSIONS: Of the patients presenting with an initial FRI in the YNHH system, one in twelve will experience another firearm injury within the next 5 years. These data indicate that firearm-related reinjury is common in Connecticut and suggest the need for further violence prevention efforts.

Assessing the Race, Ethnicity, and Gender Inequities in Blood Alcohol Testing After Trauma.

INTRODUCTION: Alcohol use remains a significant contributing factor in traumatic injuries in the United States, resulting in substantial patient morbidity and societal cost. Because of this, the American College of Surgeons Verification, Review, and Consultation Program requires the screening of 80% of trauma admissions. Multiple studies suggest that patients who use alcohol are subject to stigma by health care providers and may ultimately face legal and financial ramifications of a positive alcohol screening test. There is also evidence that sociodemographic factors may dictate drug and alcohol screening patterns among patients. Because this screening target is often not uniformly achieved among all patients presenting with injury, we sought to investigate whether there are any discrepancies in screening across sociodemographic groups. METHODS: We investigated the Trauma Quality Program Participant User File for all trauma cases admitted during 2017 and compared the rates of the serum alcohol screening test across different demographic factors, including race and ethnicity. We then performed an adjusted multivariable logistic regression to determine the odds ratio (OR) for receiving a test based on these demographic factors adjusted for hospital and clinical factors. RESULTS: There were 729,174 traumas included in the study. Of this group, 345,315 (47.4%) were screened with a serum alcohol test. Screening rates varied by injury mechanism and were highest among motorcycle crashes (66.0% of patients screened) and lowest among falls (32.8% of patients screened). Overall, Asian and Pacific Islander (52.5% screened), Black (57.7% screened), and other race (58.4% screened) had higher rates of alcohol screening than White patients (43.7% screened, P < 0.001). Similarly, Hispanic patients were screened at higher rates than non-Hispanic patients (56.4% screening versus 46.2% screening, P < 0.001). These differences persisted across nearly all injury categories. In multivariable logistic regression, Asian and Pacific Islanders were associated with the highest odds of being screened (OR 1.34, P < 0.001) followed by other race (OR 1.25, P < 0.001) in comparison to White patients. CONCLUSIONS: There are consistent and significant differences in alcohol screening rates across race and ethnicity, despite accounting for injury mechanism and comorbidities.

"The cops didn't make it any better": Perspectives on police and guns among survivors of gun violence.

BACKGROUND: Survivors of gun violence in the United States (US) are twenty times more likely to be re-injured with a firearm and three times more likely to be arrested under a violence or a weapons-related charge. The mechanisms for these outcomes are multifactorial and remain largely understudied. We aimed to examine perspectives on both the police and guns among survivors of guns violence. METHODS: We conducted a secondary analysis of qualitative data from a study that examined the post-hospitalization recovery experience of survivors of firearm violence. Using a conceptual framework derived from sociology literature and a coding team made up of researchers, community members and former police officers, we used directed content analysis to construct themes. RESULTS: The data set included interviews with 20 survivors of gun violence that were all Black males, aged 20-51 years. The recurring themes around the police included: (1) Legal cynicism: "I don't like police, none of them"; (2) Interactions with the police in a medical setting: "The cops didn't make it any better" and (3) Ambivalence around police presence within the community: "That's their job to protect me, too." Themes related to guns in the community encompassed: (1) The availability of guns: "Getting a gun is about as easy as buying a pair of sneakers"; (2) Symbolic meaning: "Guns give them courage"; (3) Social meaning: "I just let them know: I have a gun, too." and (4) Strategic meaning: "It's just for protection." CONCLUSIONS: Survivors of gun violence describe distrust for the police and an ecology of guns that confers symbolic, social and strategic meaning to owning a gun. Interventions to decrease gun violence should address the cultural value of a gun as well as focus on improving police relations with the community.

Rural Communities and Violence.

Among US geographic regions classified as rural, death rates are significantly higher for children and teens as compared with their urban peers; the disparity is even greater for Alaskan Native/American Indian and non-Hispanic black youth. Violence-related injuries and death contribute significantly to this finding. This article describes the epidemiology of violence-related injuries, with a limited discussion on child abuse and neglect and an in-depth analysis of self-inflicted injuries including unintentional firearm injuries and adolescent suicide. Potential interventions are also addressed, including strategies for injury prevention, such as firearm safe storage practices.

Financial Hardship After Traumatic Injury: Risk Factors and Drivers of Out-of-Pocket Health Expenses.

BACKGROUND: Trauma-related disorders rank among the top five most costly medical conditions to the health care system. However, the impact of out-of-pocket (OOP) health expenses for traumatic conditions is not known. In this cross-sectional study, we use nationally representative data to investigate whether patients with a traumatic injury experienced financial hardship from OOP health expenses. METHODS: Using data from the Medical Expenditure Panel Survey from 2010 to 2015, we analyzed the financial burden associated with a traumatic injury. Primary outcomes were excess financial burden (OOP>20% of annual income) and catastrophic medical expenses (OOP>40% of annual income). A multivariable logistic regression analysis evaluated whether these outcomes were associated with traumatic injury, adjusting for demographic, socioeconomic, and health care factors. We then completed a descriptive analysis to elucidate drivers of total OOP expenses. RESULTS: Of the 90,964 families in the cohort, 6434 families had a traumatic injury requiring a visit to the emergency room and 668 families had a traumatic injury requiring hospitalization. Overall 1 in 8 households with an injured family member requiring hospitalization experienced financial hardship. These families were more likely to experience excess financial burden (OR: 2.04, 95% CI: 1.13-3.64) and catastrophic medical expenses (OR: 3.08, 95% CI: 1.37-6.9). The largest burden of OOP expenses was due to prescription drug costs, with inpatient costs as a major driver of OOP expenses for those requiring hospitalization. CONCLUSIONS: Households with an injured family member requiring hospitalization are significantly more vulnerable to financial hardship from OOP health expenses than the noninjured population. Prescription drug and inpatient costs were the most significant drivers of OOP health expenses.

Survivors of gun violence and the experience of recovery.

BACKGROUND: Survivors of gun violence may develop significant mental health sequelae and are at higher risk for reinjury through repeat violence. Despite this, survivors of gun violence often return to the community where they were injured with suboptimal support for their mental health, emotional recovery, and well-being. The goal of this study was to characterize the posthospitalization recovery experience of survivors of gun violence. METHODS: We conducted a qualitative research study with a community-based participatory research approach. In partnership with a community-based organization, we conducted in-depth one-on-one interviews and used snowball sampling to recruit survivors of gun violence. We applied the constant comparison method of qualitative analysis to catalogue interview transcript data by assigning conceptual codes and organizing them into a consensus list of themes. We presented the themes back to the participants and community members for confirmation. RESULTS: We conducted 20 interviews with survivors of gun violence; all were black men, aged 20 years to 51 years. Five recurring themes emerged: (1) Isolation, physical and social restriction due to fear of surroundings; (2) Protection, feeling unsafe leading to the desire to carry a gun; (3) Aggression, willingness to use a firearm in an altercation; (4) Normalization, lack of reaction driven by the ubiquity of gun violence in the community; and (5) Distrust of health care providers, a barrier to mental health treatment. CONCLUSION: Survivors of gun violence describe a disrupted sense of safety following their injury. As a result, they experience isolation, an increased need to carry a firearm, a normalization of gun violence, and barriers to mental health treatment. These maladaptive reactions suggest a mechanism for the violent recidivism seen among survivors of gun violence and offer potential targets to help this undertreated, high-risk population. LEVEL OF EVIDENCE: Care management/Therapeutic V.

When to Admit to Observation: Predicting Length of Stay for Anticoagulated Elderly Fall Victims.

BACKGROUND: Geriatric patients who fall while taking an anticoagulant have a small but significant risk of delayed intracranial hemorrhage requiring observation for 24 h. However, the medical complexity associated with geriatric care may necessitate a longer stay in the hospital. Little is known about the factors associated with a successful observational status stay (<2 d) for this population. MATERIALS AND METHODS: Elderly patients who fell while taking an anticoagulant admitted from 2012 to 2017 at an ACS level II trauma center were included in a retrospective cohort study to determine what factors were associated with a stay consistent with observational status. INCLUSION CRITERIA: age> 65 y old, negative initial head CT, and one of the following: INR>3.5 if on warfarin, GCS<14, external signs of trauma, or focal neurological deficits. RESULTS: The cohort included 369 patients. Factors associated with decreased likelihood of successful observational status included the need for services after discharge such as an extended care facility (OR 0.06, 95% CI 0.02-0.19, P < 0.001) or visiting nurse agency services (OR 0.27, 95% CI 0.10-0.75, P < 0.001), a dementia diagnosis (OR 0.17, 95% CI 0.04-0.70, P = 0.014), increasing number of medications (OR 0.91, 95% CI 0.84-0.99, P = 0.031), and the use of coumadin (OR 0.28, 95% CI 0.12-0.70, P = 0.006). CONCLUSIONS: For trauma providers, knowing your patient's medication use and particularly type of anticoagulant, comorbidities including dementia, and likely need for services after discharge will help guide the decision to admit the patient for what may be a reasonably lengthy stay versus a brief observation in the hospital for elderly fall victims on anticoagulation.

Physicians on the Frontlines: Understanding the Lived Experience of Physicians Working in Communities That Experienced a Mass Casualty Shooting.

This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: "I wonder if I'm broken"; (2) the importance of and need for mass casualty shooting preparedness: "[We need to] recognize this as a public health concern and train physicians to manage it"; (3) massive media attention: "The media onslaught was unbelievable"; and (4) commitment to advocacy for a public health approach to firearm violence: "I want to do whatever I can to prevent some of these terrible events."

The influence of sociodemographic factors on operative decision-making in small bowel obstruction.

BACKGROUND: Current guidelines for small bowel obstruction (SBO) recommend a limited trial of nonoperative management of no more than 3-5 d. For patients requiring surgery, it is uncertain if sociodemographic factors are associated with disparities in the duration of the trial of nonoperative therapy. METHODS: The Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 was queried for discharges with a primary diagnosis of SBO. Primary outcomes of interest were the effects of sociodemographic factors, including race, insurance status, and income on the rate of receiving any operative management for SBO, and subsequently, among patients managed surgically, the risk of operative delay, defined as operative management ≥ 5 d after admission. We did this by using logistic hierarchical generalized linear models, accounting for hospital clustering and adjusted for sex, age, comorbidity, and hospital factors. RESULTS: Of the 589,850 admissions for SBO between 2012 and 2014, 22.0% underwent operations. Overall, 26.2% were non-White, including 12.2% Black and 8.6% Hispanic patients, and the majority (56.0%) had Medicare insurance coverage. Income quartiles were evenly distributed across the overall study population. In adjusted logistic regression, operative delay was associated with increased odds of in-hospital mortality (odds ratio 1.30 95% confidence interval [1.10, 1.54]). Adjusted for patient and hospital factors, Black patients were significantly more likely to receive operations for SBO, whereas Medicaid and Medicare patients were significantly less likely. However, Black, Medicaid, and Medicare patients who were managed operatively were significantly more likely to have an operative delay of 5 or more d. There was no significant association between income and operative management in adjusted regression models. CONCLUSIONS: Significant disparities in the operative management were based on race and insurance status. Further research is warranted to understand the causes of, and solutions to, these sociodemographic disparities in care.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction.

BACKGROUND: Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. MATERIALS AND METHODS: The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. RESULTS: A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). CONCLUSIONS: This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures.

BACKGROUND: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. METHODS: We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. FINDINGS: The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. INTERPRETATION: Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti.

BACKGROUND: Women with breast cancer in low-income and middle-income countries (LMICs) account for 51% of cases globally and often present with advanced disease. Fear of costs contributes to delay in seeking care, as health expenditures are financially catastrophic for families worldwide. Despite efforts to improve affordability of health care in LMICs, the financial burden of indirect costs (eg, transportation and lost wages) is often overlooked. We aimed to identify and quantify the expenditures of patients seeking breast cancer care in a LMIC. METHODS: Patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were interviewed to quantify their costs and assess the effect of these costs on patients and families. These costs included expenses for food, lodging, transportation, childcare, medical costs at other institutions, and lost wages. 61 patients were interviewed during diagnostic, chemotherapy, and surgical visits between March 1, and May 12, 2014. Institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante. FINDINGS: The median non-medical out-of-pockent expenses incurred by breast cancer patients at HUM were US$233 (95% CI 170-304) for diagnostic visits, US$259 (95% CI 200-533) for chemotherapy, and US$38 (95% CI 23-140) for surgery. The median total out-of-pockent expense (including medical costs) was US$717 (95% CI 619-1171). These costs forced 52% of participants into debt and 20% to sell possessions. The median percentage of potential individual income spent on out-of-pocket costs was 60%. The median sum of out-of-pocket costs and lost wages was US$2996 (95% CI 1676-5179). INTERPRETATION: In Haiti, 74% of people earn less than US$2 per day. Even when breast cancer treatment is provided for free, out-of-pocket expenses could account for more than 91% of annual earnings at this income level. This financial burden is an overwhelming obstacle for Haiti's poorest citizens, and probably for many patients in LMICs. High-powered, multisite studies are needed to further characterise this burden worldwide. Funders and health-care providers should reduce indirect costs to achieve equitable access to oncology care. FUNDING: Boston Children's Hospital and Partners in Health.

Out-of-pocket expenses incurred by patients obtaining free breast cancer care in Haiti: A pilot study.

BACKGROUND: Women in low- and middle-income countries account for 51% of breast cancer cases globally. These patients often delay seeking care and, therefore, present with advanced disease, partly because of fear of catastrophic health care expenses. Although there have been efforts to make health care affordable in low- and middle-income countries, the financial burden of out-of-pocket (OOP) expenses for nonmedical costs, such as transportation and lost wages, often is overlooked. METHODS: An institutional review board exemption was granted from Boston Children's Hospital and Partners in Health/Zanmi Lasante for this cross-sectional study. In total, 61 patients receiving breast cancer care free of charge at Hôpital Universitaire de Mirebalais (HUM) in Haiti were selected via convenience sampling. They were interviewed between March and May 2014 to quantify the expenses they incurred during the course of diagnosis and treatment. These expenses included medical costs at outside facilities, as well as nonmedical costs (eg, transportation, meals, etc). RESULTS: The median, nonmedical OOP expenses incurred by breast cancer patients at HUM were $233 (95% confidence interval [95% CI] $170-304) for diagnostic visits, $259 (95% CI $200-533) for chemotherapy visits, and $38 (95% CI $23-140) for surgery visits. The median total OOP expense (including medical costs) was $717 (95% CI $619-1,171). To pay for these expenses, 52% of participants stated that they went into debt; however, the amount of debt was not quantified. The median income of these patients was $1,333 (95% CI $778-2,640), and the median sum of OOP expenses and lost wages was $2,996 (95% CI $1,676-5,179). CONCLUSION: Despite receiving free care: at HUM, more than two-thirds of participants met conservative criteria for catastrophic medical expenses (defined as spending more than 40% of their potential household income on OOP payments). Further studies are needed to understand the magnitude of OOP health care expenses for the poor worldwide, how to aid them during their treatment program, and its impact on their health outcomes.

What role does body mass index play in hospital admission rates from the pediatric emergency department?

BACKGROUND: The primary objective of this study was to determine if children with abnormal body mass index (BMI) percentiles for age were admitted to the hospital from the emergency room at greater frequency than normal-weight children. This study also sought to evaluate what specific diagnoses both underweight and overweight children were being admitted with, and if a discrepancy exists. METHODS: A prospective observational chart review was conducted of children evaluated in the emergency department of the Children's Hospital at the University of Oklahoma during the month of October 2011 (n = 1747). One thousand nine hundred thirteen patient charts were reviewed, but 166 were excluded because of inability to obtain a height or weight within a 3-month period of the child being seen in the emergency department. RESULTS: Thirty-five (24.5%) of underweight patients, 82 (14.6%) of overweight or obese, and 173 (16.6%) of the normal-weight patients were admitted to the hospital from the emergency department. The underweight patients were admitted more frequently than the normal-weight (P = 0.0206) and overweight or obese patients (P = 0.0046). In addition, underweight patients were admitted more frequently with respiratory infections than normal-weight (P = 0.0279) and overweight or obese (P = 0.0509) patients. In addition, underweight patients were admitted more than overweight or obese patients with fractures (P = 0.0278). There was no statistical difference between overweight or obese and normal-weight admissions within any of the diagnostic categories. CONCLUSIONS: Underweight children (BMI ≤5%) have an increased risk of hospitalization from the emergency department, even when adjusted for age and sex. In particular, hospitalization among underweight patients was increased for those patients with respiratory infections and fractures. No difference was seen between admission rates of overweight (BMI ≥85%) or obese (BMI ≥95%) patients from those of normal-weight patients. This warrants the need to counsel patients and their families on the dangers not only of obesity, but also of being underweight. Emphasis should be placed on healthy lifestyles that include well-balanced meals and exercise.