Clinical risk factors and blood protein biomarkers of 10-year pneumonia risk.

Background: Chronic inflammation may increase susceptibility to pneumonia. Research Question: To explore associations between clinical comorbidities, serum protein immunoassays, and long-term pneumonia risk. Methods: Framingham Heart Study Offspring Cohort participants ≥65 years were linked to their Centers for Medicare Services claims data. Clinical data and 88 serum protein immunoassays were evaluated for associations with 10-year incident pneumonia risk using Fine-Gray models for competing risks of death and least absolute shrinkage and selection operators for covariate selection. Results: We identified 1,370 participants with immunoassays and linkage to Medicare data. During 10 years of follow up, 428 (31%) participants had a pneumonia diagnosis. Chronic pulmonary disease [subdistribution hazard ratio (SHR) 1.87; 95% confidence interval (CI), 1.33-2.61], current smoking (SHR 1.79, CI 1.31-2.45), heart failure (SHR 1.74, CI 1.10-2.74), atrial fibrillation/flutter (SHR 1.43, CI 1.06-1.93), diabetes (SHR 1.36, CI 1.05-1.75), hospitalization within one year (SHR 1.34, CI 1.09-1.65), and age (SHR 1.06 per year, CI 1.04-1.08) were associated with pneumonia. Three baseline serum protein measurements were associated with pneumonia risk independent of measured clinical factors: growth differentiation factor 15 (SHR 1.32; CI 1.02-1.69), C-reactive protein (SHR 1.16, CI 1.06-1.27) and matrix metallopeptidase 8 (SHR 1.14, CI 1.01-1.30). Addition of C-reactive protein to the clinical model improved prediction (Akaike information criterion 4950 from 4960; C-statistic of 0.64 from 0.62). Conclusions: Clinical comorbidities and serum immunoassays were predictive of pneumonia risk. C-reactive protein, a routinely-available measure of inflammation, modestly improved pneumonia risk prediction over clinical factors. Our findings support the hypothesis that prior inflammation may increase the risk of pneumonia.

An artificial intelligence model that automatically labels roux-en-Y gastric bypasses, a comparison to trained surgeon annotators.

INTRODUCTION: Artificial intelligence (AI) can automate certain tasks to improve data collection. Models have been created to annotate the steps of Roux-en-Y Gastric Bypass (RYGB). However, model performance has not been compared with individual surgeon annotator performance. We developed a model that automatically labels RYGB steps and compares its performance to surgeons. METHODS AND PROCEDURES: 545 videos (17 surgeons) of laparoscopic RYGB procedures were collected. An annotation guide (12 steps, 52 tasks) was developed. Steps were annotated by 11 surgeons. Each video was annotated by two surgeons and a third reconciled the differences. A convolutional AI model was trained to identify steps and compared with manual annotation. For modeling, we used 390 videos for training, 95 for validation, and 60 for testing. The performance comparison between AI model versus manual annotation was performed using ANOVA (Analysis of Variance) in a subset of 60 testing videos. We assessed the performance of the model at each step and poor performance was defined (F1-score < 80%). RESULTS: The convolutional model identified 12 steps in the RYGB architecture. Model performance varied at each step [F1 > 90% for 7, and > 80% for 2]. The reconciled manual annotation data (F1 > 80% for > 5 steps) performed better than trainee's (F1 > 80% for 2-5 steps for 4 annotators, and < 2 steps for 4 annotators). In testing subset, certain steps had low performance, indicating potential ambiguities in surgical landmarks. Additionally, some videos were easier to annotate than others, suggesting variability. After controlling for variability, the AI algorithm was comparable to the manual (p < 0.0001). CONCLUSION: AI can be used to identify surgical landmarks in RYGB comparable to the manual process. AI was more accurate to recognize some landmarks more accurately than surgeons. This technology has the potential to improve surgical training by assessing the learning curves of surgeons at scale.

Surgical workflow recognition with temporal convolution and transformer for action segmentation.

PURPOSE: Automatic surgical workflow recognition enabled by computer vision algorithms plays a key role in enhancing the learning experience of surgeons. It also supports building context-aware systems that allow better surgical planning and decision making which may in turn improve outcomes. Utilizing temporal information is crucial for recognizing context; hence, various recent approaches use recurrent neural networks or transformers to recognize actions. METHODS: We design and implement a two-stage method for surgical workflow recognition. We utilize R(2+1)D for video clip modeling in the first stage. We propose Action Segmentation Temporal Convolutional Transformer (ASTCFormer) network for full video modeling in the second stage. ASTCFormer utilizes action segmentation transformers (ASFormers) and temporal convolutional networks (TCNs) to build a temporally aware surgical workflow recognition system. RESULTS: We compare the proposed ASTCFormer with recurrent neural networks, multi-stage TCN, and ASFormer approaches. The comparison is done on a dataset comprised of 207 robotic and laparoscopic cholecystectomy surgical videos annotated for 7 surgical phases. The proposed method outperforms the compared methods achieving a [Formula: see text] relative improvement in the average segmental F1-score over the state-of-the-art ASFormer method. Moreover, our proposed method achieves state-of-the-art results on the publicly available Cholec80 dataset. CONCLUSION: The improvement in the results when using the proposed method suggests that temporal context could be better captured when adding information from TCN to the ASFormer paradigm. This addition leads to better surgical workflow recognition.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team.

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

Intermittent claudication treatment patterns in the commercially insured non-Medicare population.

OBJECTIVE: Despite published guidelines and data for Medicare patients, it is uncertain how younger patients with intermittent claudication (IC) are treated. Additionally, the degree to which treatment patterns have changed over time with the expansion of endovascular interventions and outpatient centers is unclear. Our goal was to characterize IC treatment patterns in the commercially insured non-Medicare population. METHODS: The IBM MarketScan Commercial Database, which includes more than 8 billion US commercial insurance claims, was queried for patients newly diagnosed with IC from 2007 to 2016. Patient demographics, medication profiles, and open/endovascular interventions were evaluated. Time trends were modeled using simple linear regression and goodness-of-fit was assessed with coefficients of determination (R2). A patient-centered cohort sample and a procedure-focused dataset were analyzed. RESULTS: Among 152,935,013 unique patients in the database, there were 300,590 patients newly diagnosed with IC. The mean insurance coverage was 4.4 years. The median patients age was 58 years and 56% of patients were male. The prevalence of statin use was 48% among patients at the time of IC diagnosis and increased to 52% among patients after one year from diagnosis. Interventions were performed in 14.3%, of whom 20% and 6% underwent two or more and three or more interventions, respectively. The median time from diagnosis to intervention decreased from 230 days in 2008 days to 49 days in 2016 (R2 = 0.98). There were 16,406 inpatient and 102,925 ambulatory interventions for IC over the study period. Among ambulatory interventions, 7.9% were performed in office-based/surgical centers. The proportion of atherectomies performed in the ambulatory setting increased from 9.7% in 2007 to 29% in 2016 (R2 = 0.94). In office-based/surgical centers, 57.6% of interventions for IC used atherectomy in 2016. Atherectomy was used in ambulatory interventions by cardiologists in 22.6%, surgeons in 15.2%, and radiologists in 13.6% of interventions. Inpatient atherectomy rates remained stable over the study period. Open and endovascular tibial interventions were performed in 7.9% and 7.8% of ambulatory and inpatient IC interventions, respectively. Tibial bypasses were performed in 8.2% of all open IC interventions. CONCLUSIONS: There has been shorter time to intervention in the treatment of younger, commercially insured patients with IC, with many receiving multiple interventions. Statin use was low. Ambulatory procedures, especially in office-based/surgical centers, increasingly used atherectomy, which was not observed in inpatient settings.

Prevalence and hospital charges from firearm injuries treated in US emergency departments from 2006 to 2016.

BACKGROUND: Age- and intent-related differences in the burden and costs of firearm injury treated in emergency departments are not well-documented. METHODS: We performed a serial cross-sectional study of the Healthcare Cost and Utilization Program Nationwide Emergency Department Survey from 2006 to 2016. We used International Classification of Diseases diagnoses codes revisions 9 and 10 to identify firearm injuries. We calculated survey-weighted counts, proportions, means, and rates and confidence intervals of national, age-specific (0-4, 5-9, 10-14, 15-17, 18-44, 45-64, 65-84, >84) and intent-specific (assault, unintentional, suicide, undetermined) emergency department discharges for firearm injuries. We used survey-weighted regression to assess temporal trends. RESULTS: There was a total of 868,483 (25.5 per 100,000) emergency department visits for firearm injuries from 2006 to 2016, and 7.8% died in the emergency department. Overall, firearm injury rates remained steady (P = .78). The largest burden was among those 25 to 44 years of age, but their rates remained stable (10.8 per 100,000). Overall assault injuries declined from 39.7% to 36.4%, and overall unintentional injuries increased from 46.4% to 54.7%. Legal-intervention injuries declined from 0.6 to 0.3 per 100,000. The charges (total $4,059,070,364, $369,006,396/year) increased across time in age and intent groups. The mean predicted charges increased from $1,922 to $3,348 in those alive versus $3,741 to $6,515 among those who died. CONCLUSION: Interventions and programs to manage the consequences of firearm injury in persons who live with ongoing morbidity and economic burden are warranted.

Hospital-Level Medicaid Prevalence Is Associated with Increased Length of Stay after Asymptomatic Carotid Endarterectomy and Stenting Despite no Increase in Major Complications.

BACKGROUND: Length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) for asymptomatic disease is used as a quality measure and affects hospital operating margins. Patient-level Medicaid status has traditionally been associated with longer hospital LOS. Our goal was to assess the association between hospital-level Medicaid prevalence and postoperative LOS after CEA and CAS. METHODS: The National Inpatient Sample was queried from 2006-2014 for CEA and CAS performed for asymptomatic carotid stenosis. Overall hospital-level Medicaid prevalence was divided into quartiles. The quartiles were further categorized into low Medicaid prevalence (LM) (lowest quartile), medium Medicaid prevalence (MM) (second and third quartiles), and high Medicaid prevalence (HM) (fourth quartile) cohorts. The primary outcome evaluated was postoperative LOS >1 day. The secondary outcomes included perioperative/in-hospital complications and mortality. RESULTS: There were 984,283 patients with asymptomatic carotid stenosis who underwent CEA (88%) or CAS (12%). Mean postoperative LOS after CEA at hospitals with LM, MM, and HM prevalence was 1.4 ± 1.5, 2.1 ± 2.5, and 2.2 ± 2.8 days (P = 0.0001), respectively, and after CAS were 1.7 ± 2.6, 1.8 ± 2.1, and 2 ± 2.6 days (P < 0.0001), respectively. After CEA, relative to LM prevalence, MM (OR 1.62, 95% CI 1.17-2.24) and HM (OR 1.66, 95% CI 1.2-2.28) prevalence were associated with a higher likelihood of LOS > 1 day (P = 0.009). After CAS, relative to LM prevalence, HM prevalence was associated with a higher likelihood of LOS >1 day (OR 1.42, 95% CI 1.06-1.91) (P = 0.003). After CEA, neurologic (0.8% vs. 0.9% vs. 0.9%, P = 0.83) and cardiac complications (0.9% vs. 1.2% vs. 1.2%, P = 0.24) were similar among hospitals with LM, MM, and HM prevalence, respectively. After CAS, the prevalence of neurological (1.1% vs. 1% vs. 1.2%, P = 0.42) and cardiac complications (2% vs. 1.3% vs. 1.5%, P = 0.46) were also similar. After both CEA and CAS, mortality was similar among Medicaid prevalence cohorts. CONCLUSIONS: Higher hospital-level Medicaid prevalence was associated with longer LOS after CEA and CAS for asymptomatic carotid stenosis. Value-based payment models should adjust for hospital-level Medicaid prevalence to appropriately reimburse providers and hospital with higher Medicaid prevalence as well as investigate care pathways and systems improvement to help reduce LOS.

Against Medical Advice Discharges in Injection and Non-injection Drug Use-associated Infective Endocarditis: A Nationwide Cohort Study.

BACKGROUND: Among those with injection drug use-associated infective endocarditis (IDU-IE), against medical advice (AMA) discharge is common and linked to adverse outcomes. Understanding trends, risk factors, and timing is needed to reduce IDU-IE AMA discharges. METHODS: We identified individuals ages 18-64 with International Classification of Diseases, 9thRevision, diagnosis codes for infective endocarditis (IE) in the National Inpatient Sample, a representative sample of United States hospitalizations from January 2010 to September 2015. We plotted unadjusted quarter-year trends for AMA discharges and used multivariable logistic regression to identify factors associated with AMA discharge among IE hospitalizations, comparing IDU-IE with non-IDU-IE. RESULTS: We identified 7259 IDU-IE and 23 633 non-IDU-IE hospitalizations. Of these hospitalizations, 14.2% of IDU-IE and 1.9% of non-IDU-IE resulted in AMA discharges. More than 30% of AMA discharges for both groups occurred before hospital day 3. In adjusted models, IDU status (adjusted odds ratio [AOR], 3.92; 95% confidence interval [CI], 3.43-4.48)] was associated with increased odds of AMA discharge. Among IDU-IE, women (AOR, 1.21; 95% CI, 1.04-1.41) and Hispanics (AOR, 1.32; 95% CI, 1.03-1.69) had increased odds of AMA discharge, which differed from non-IDU-IE. Over nearly 6 years, odds of AMA discharge increased 12% per year for IDU-IE (AOR, 1.12; 95% CI, 1.07-1.18) and 6% per year for non-IDU-IE (AOR, 1.06; 95% CI. 1.00-1.13). CONCLUSIONS: AMA discharges have risen among individuals with IDU-IE and non-IDE-IE. Among those who inject drugs, AMA discharges were more common and increases sharper. Efforts that address the rising fraction, disparities, and timing of IDU-IE AMA discharges are needed.

Utilization of mental health services in pediatric patients surviving penetrating trauma resulting from interpersonal violence.

BACKGROUND: Violent trauma has lasting psychological impacts. Our institution's Community Violence Response Team (CVRT) offers mental health services to trauma victims. We characterized implementation and determined factors associated with utilization by pediatric survivors of interpersonal violence-related penetrating trauma. METHODS: Analysis included survivors (0-21 years) of violent penetrating injury at our institution (2011-2017). Injury and demographic data were collected. Nonparametric regression models determined factors associated with utilization. RESULTS: There was initial rapid uptake of CVRT (2011-2013) after which it plateaued, serving >80% of eligible patients (2017). White race and higher injury severity were associated with receipt and duration of services. In post-hoc analysis, race was found to be associated with continued treatment but not with initial consultation. CONCLUSION: Successful implementation required three years, aiding >80% of patients. CVRT is a blueprint to strengthen existing violence intervention programs. Efforts should be made to ensure that barriers to providing care, including those related to race, are overcome.

Clinical diagnostic phenotypes in hospitalizations due to self-inflicted firearm injury.

BACKGROUND: . Hospitalized self-inflicted firearm injuries have not been extensively studied, particularly regarding clinical diagnoses at the index admission. The objective of this study was to discover the diagnostic phenotypes (DPs) or clusters of hospitalized self-inflicted firearm injuries. METHODS: . Using Nationwide Inpatient Sample data in the US from 1993 to 2014, we used International Classification of Diseases, Ninth Revision codes to identify self-inflicted firearm injuries among those ≥18 years of age. The 25 most frequent diagnostic codes were used to compute a dissimilarity matrix and the optimal number of clusters. We used hierarchical clustering to identify the main DPs. RESULTS: . The overall cohort included 14072 hospitalizations, with self-inflicted firearm injuries occurring mainly in those between 16 to 45 years of age, black, with co-occurring tobacco and alcohol use, and mental illness. Out of the three identified DPs, DP1 was the largest (n=10,110), and included most common diagnoses similar to overall cohort, including major depressive disorders (27.7%), hypertension (16.8%), acute post hemorrhagic anemia (16.7%), tobacco (15.7%) and alcohol use (12.6%). DP2 (n=3,725) was not characterized by any of the top 25 ICD-9 diagnoses codes, and included children and peripartum women. DP3, the smallest phenotype (n=237), had high prevalence of depression similar to DP1, and defined by fewer fatal injuries of chest and abdomen. LIMITATIONS: . Claims data. CONCLUSIONS: . There were three distinct diagnostic phenotypes in hospitalizations due to self-inflicted firearm injuries. Further research is needed to determine how DPs can be used to tailor clinical care and prevention efforts.

Intersections of Firearm Suicide, Drug-Related Mortality, and Economic Dependency in Rural America.

BACKGROUND: Rural counties in the United States have higher firearm suicide rates and opioid overdoses than urban counties. We sought to determine whether rural counties can be grouped based on these "diseases of despair." METHODS: Age-adjusted firearm suicide death rates per 100,000; drug-related death rates per 100,000; homicide rate per 100,000, opioid prescribing rate, %black, %Native American, and %veteran population, median home price, violent crime rates per 100,000, primary economic dependency (nonspecialized, farming, mining, manufacturing, government, and recreation), and economic variables (low education, low employment, retirement destination, persistent poverty, and persistent child poverty) were obtained for all rural counties and evaluated with hierarchical clustering using complete linkage. RESULTS: We identified five distinct rural county clusters. The firearm suicide rates in the clusters were 5.9, 6.8, 6.4, 8.5, and 3.8 per 100,000, respectively. The counties in cluster 1 were poor, mining dependent, with population loss, cluster 2 were nonspecialized economies, with high opioid prescription rates, cluster 3 were manufacturing and government economies with moderate unemployment, cluster 4 were recreational economies with substantial veterans and Native American populations, high median home price, drug death rates, opioid prescribing, and violent crime, and cluster 5 were farming economies, with high population loss, low median home price, low rates of drug mortality, opioid prescribing, and violent crime. Cluster 4 counties were spatially adjacent to urban counties. CONCLUSIONS: More than 300 counties currently face a disproportionate burden of diseases of despair. Interventions to reduce firearm suicides should be community-based and include programs to reduce other diseases of despair.

Lower extremity vascular injuries caused by firearms have a higher risk of amputation and death compared with non-firearm penetrating trauma.

OBJECTIVE: Firearm injuries have traditionally been associated with worse outcomes compared with other types of penetrating trauma. Lower extremity trauma with vascular injury is a common presentation at many centers. Our goal was to compare firearm and non-firearm lower extremity penetrating injuries requiring vascular repair. METHODS: We analyzed the National Inpatient Sample from 2010 to 2014 for all penetrating lower extremity injuries requiring vascular repair based on International Classification of Diseases, Ninth Revision codes. Our primary outcomes were in-hospital lower extremity amputation and death. RESULTS: We identified 19,494 patients with lower extremity penetrating injuries requiring vascular repair-15,727 (80.7%) firearm injuries and 3767 (19.3%) non-firearm injuries. The majority of patients were male (91%), and intent was most often assault/legal intervention (64.3%). In all penetrating injuries requiring vascular repair, the majority (72.9%) had an arterial injury and 43.8% had a venous injury. Location of vascular injury included iliac (19.3%), femoral-popliteal (60%), and tibial (13.2%) vascular segments. Interventions included direct vascular repair (52.1%), ligation (22.1%), bypass (19.4%), and endovascular procedures (3.6%). Patients with firearm injuries were more frequently younger, black, male, and on Medicaid, with lower household income, intent of assault or legal action, and two most severe injuries in the same body region (P < .0001 for all). Firearm injuries compared with non-firearm injuries were more often reported to be arterial (75.5% vs 61.9%), to involve iliac (20.6% vs 13.7%) and femoral-popliteal vessels (64.7% vs 39.9%), to undergo endovascular repair (4% vs 2.1%), and to have a bypass (22.5% vs 6.5%; P < .05 for all). Firearm-related in-hospital major amputation (3.3% vs 0.8%; P = .001) and mortality (7.6% vs 4.2%; P = .001) were higher compared with non-firearm penetrating trauma. Multivariable analysis showed that injury by a firearm source was independently associated with postoperative major amputation (odds ratio, 4.78; 95% confidence interval, 2.07-11.01; P < .0001) and mortality (odds ratio, 1.74; 95% confidence interval, 1.14-2.65; P = .01). CONCLUSIONS: Firearm injury is associated with a higher rate of amputation and mortality compared with non-firearm injuries of the lower extremity requiring vascular repair. These data can continue to guide public health discussions about morbidity and mortality from firearm injury.

Effect of Publicly Reported Aortic Valve Surgery Outcomes on Valve Surgery in Injection Drug- and Non-Injection Drug-Associated Endocarditis.

BACKGROUND: Injection drug use-associated infective endocarditis (IDU-IE) is rising and valve surgery is frequently indicated. The effect of initiating public outcomes reporting for aortic valve surgery on rates of valve surgery and in-hospital mortality for endocarditis is not known. METHODS: For an interrupted time series analysis, we used data from the National Inpatient Sample, a representative sample of United States inpatient hospitalizations, from January 2010 to September 2015. We included individuals aged 18-65 with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of endocarditis. We defined IDU-IE using a validated combination of ICD-9 codes. We used segmented logistic regression to assess for changes in valve replacement and in-hospital mortality rates after the public reporting initiation in January 2013. RESULTS: We identified 7322 hospitalizations for IDU-IE and 23 997 for non-IDU-IE in the sample, representing 36 452 national IDU-IE admissions and 119 316 non-IDU admissions, respectively. Following the implementation of public reporting in 2013, relative to baseline trends, the odds of valve replacement decreased by 4.0% per quarter (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99), with no difference by IDU status. The odds of an in-patient death decreased by 2.0% per quarter for both IDU-IE and non-IDU-IE cases following reporting (OR 0.98, 95% CI 0.97-0.99). CONCLUSIONS: Initiating public reporting was associated with a significant decrease in valve surgery for all IE cases, regardless of IDU status, and a reduction in-hospital mortality for patients with IE. Patients with IE may have less access to surgery as a consequence of public reporting. To understand how reduced valve surgery impacts overall mortality, future studies should examine the postdischarge mortality rate.

Changes in patterns of mortality rates and years of life lost due to firearms in the United States, 1999 to 2016: A joinpoint analysis.

BACKGROUND: Firearm-related death rates and years of potential life lost (YPLL) vary widely between population subgroups and states. However, changes or inflections in temporal trends within subgroups and states are not fully documented. We assessed temporal patterns and inflections in the rates of firearm deaths and %YPLL due to firearms for overall and by sex, age, race/ethnicity, intent, and states in the United States between 1999 and 2016. METHODS: We extracted age-adjusted firearm mortality and YPLL rates per 100,000, and %YPLL from 1999 to 2016 by using the WONDER (Wide-ranging Online Data for Epidemiologic Research) database. We used Joinpoint Regression to assess temporal trends, the inflection points, and annual percentage change (APC) from 1999 to 2016. RESULTS: National firearm mortality rates were 10.3 and 11.8 per 100,000 in 1999 and 2016, with two distinct segments; a plateau until 2014 followed by an increase of APC = 7.2% (95% CI 3.1, 11.4). YPLL rates were from 304.7 and 338.2 in 1999 and 2016 with a steady APC increase in %YPLL of 0.65% (95% CI 0.43, 0.87) from 1999 to an inflection point in 2014, followed by a larger APC in %YPLL of 5.1% (95% CI 0.1, 10.4). The upward trend in firearm mortality and YPLL rates starting in 2014 was observed in subgroups of male, non-Hispanic blacks, Hispanic whites and for firearm assaults. The inflection points for firearm mortality and YPLL rates also varied across states. CONCLUSIONS: Within the United States, firearm mortality rates and YPLL remained constant between 1999 and 2014 and has been increasing subsequently. There was, however, an increase in firearm mortality rates in several subgroups and individual states earlier than 2014.

Injury Burden in the United States: Accurate, Reliable, and Timely Surveillance Using Electronic Health Care Data.

Current injury surveillance systems in the United States, including the National Electronic Injury Surveillance System (NEISS), are unable to draw reliable subnational and subannual incidence estimates.Compared with the International Classification of Diseases (ICD), the clinical ontology system currently used widely in health care, NEISS's coding structure lacks specificity and consistency. In parallel, the quality of ICD codes depends on accurate and complete documentation by health care providers and skillful translation into ICD codes in electronic health care data. Additionally, there is no national mandate to collect external cause of injury data.Electronic health care data, such as health records and claims, with updated codes and uniform adherence to recommendations for coding external cause of injury, have the potential to be used for a more robust and timely surveillance of injury to accurately and reliably reflect the injury burden in the United States.

Pre-operative stress testing in the evaluation of patients undergoing non-cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Pre-operative stress testing is widely used to evaluate patients for non-cardiac surgeries. However, its value in predicting peri-operative mortality is uncertain. The objective of this study is to assess the type and quality of available evidence in a comprehensive and statistically rigorous evaluation regarding the effectiveness of pre-operative stress testing in reducing 30-day post -operative mortality following non -cardiac surgery. METHODS: The databases of MEDLINE, EMBASE, and CENTRAL databases (from inception to January 27, 2016) were searched for all studies in English. We included studies with pre-operative stress testing prior to 10 different non-cardiac surgery among adults and excluded studies with sample size<15. The data on study characteristics, methodology and outcomes were extracted independently by two observers and checked by two other observers. The primary outcome was 30-day mortality. We performed random effects meta-analysis to estimate relative risk (RR) and 95% confidence intervals (95% CI) in two-group comparison and pooled the rates for stress test alone. Heterogeneity was assessed using I2 and methodological quality of studies using Newcastle-Ottawa Quality Assessment Scale. The predefined protocol was registered in PROSPERO #CRD42016049212. RESULTS: From 1807 abstracts, 79 studies were eligible (297,534 patients): 40 had information on 30-day mortality, of which 6 studies compared stress test versus no stress test. The risk of 30-day mortality was not significant in the comparison of stress testing versus none (RR: 0.79, 95% CI = 0.35-1.80) along with weak evidence for heterogeneity. For the studies that evaluated stress testing without a comparison group, the pooled rates are 1.98% (95% CI = 1.25-2.85) with a high heterogeneity. There was evidence of potential publication bias and small study effects. CONCLUSIONS: Despite substantial interest and research over the past 40 years to predict 30-day mortality risk among patients undergoing non-cardiac surgery, the current body of evidence is insufficient to derive a definitive conclusion as to whether stress testing leads to reduced peri-operative mortality.

Population-Based Analysis of Firearm Injuries among Young Children in the United States, 2010-2015.

Firearm violence in the United States knows no age limit. This study compares the survival of children younger than five years to children and adolescents of age 5-19 years who presented to an ED for gunshot wounds (GSWs) in the United States to test the hypothesis of higher GSW mortality in very young children. A study of GSW patients aged 19 years and younger who survived to reach medical care was performed using the Nationwide ED Sample for 2010-2015. Hospital survival and incidence of fatal and nonfatal GSWs in the United States were the study outcomes. A multilevel logistic regression model estimated the strength of association among predictors of hospital mortality. The incidence of ED presentation for GSW is as high as 19 per 100,000 population per year. Children younger than five years were 2.7 times as likely to die compared with older children (15.3% vs 5.6%). Children younger than one year had the highest hospital mortality, 33.1 per cent. The mortality from GSW is highest among the youngest children compared with older children. This information may help policy makers and the public better understand the impact of gun violence on the youngest and most vulnerable Americans.

Divergent Temporal Trends in Morbidity and Mortality Related to Heart Failure and Atrial Fibrillation: Age, Sex, Race, and Geographic Differences in the United States, 1991-2015.

Background Heart failure ( HF ) and atrial fibrillation ( AF ) are rising in prevalence and pose a substantial public health burden. Methods and Results We evaluated temporal trends specific to age, sex, race, and geographic region in rates of HF - and AF -related morbidity, mortality, and years of potential life lost at age 75 years between 1991 and 2015 in the United States. For trends in hospitalization with a primary diagnosis of HF versus AF , we used data for patients aged ≥30 years from 1993 to 2014 from the Nationwide Inpatient Sample. For trends in death due to HF versus AF , we used data from 1991 to 2015 from the National Center for Health Statistics. Over the past 25 years, the age-adjusted rates of hospitalization declined for HF (-1.72% per year) but increased for AF (+1.61% per year). HF mortality rates remained unchanged, whereas those for AF increased (+11.2% per year). Years of potential life lost increased for both HF (+0.4% per year) and AF (+9.8% per year). Trends in HF and AF morbidity rates varied moderately by age group, whereas mortality rates varied by age and race. HF and AF hospitalization and mortality rates rose for individuals aged <50 years. HF hospitalization rates declined in all 4 US census regions, whereas AF rates increased. Conclusions We observed divergent trends of decreasing hospitalization and mortality rates for HF versus increasing rates for AF . Variations in disease burden by race and geography warrant specific targeting of "at risk" groups in selected US regions. Additional studies are warranted to evaluate the rising burden of both conditions in younger adults.