Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers.

BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.

The costs of traumatic head injury and associated factors at University of Gondar Specialized Referral Hospital, Northwest Ethiopia.

BACKGROUND: Head injuries account for 650,000 annual deaths worldwide. The cost for treating head injury was estimated at US $200 million annually. This contributes to economic impoverishment in low income countries like Ethiopia. Hence, this study was aimed to assess the cost of Traumatic Head Injury (THI) and associated factors in the University of Gondar Specialized Referral Hospital. METHOD: An institution-based cross-sectional study was conducted from March 01 to May 30, 2017. A total of 387 THI patients were included in the study. An interviewer-administered questionnaire was used for data collection. Direct costs and indirect costs were measured by using the bottom-up approach. Data were entered into Epi-Info version 7 and imported to SPSS version 20 for analysis. Simple and multiple linear regression analysis were done to identify factors associated with cost of THI. RESULTS: The mean cost of THI per patient was 4673.43 Ethiopian Birr (ETB), 95% CI (4523.6-4823.3), and length of hospital stay averaged 1.73, 95% CI (1.63-1.82). Direct non-medical cost, like transportation fee 1896.19 ETB (±762.56 SD) and medical costs 1101.66 ETB (±534.13 SD) were account for 40.57 and 23.58% of total costs respectively. The indirect cost, loss of income by patient and their attendant due to injury, was 1675.58 ETB (+ 459.26 SD). Patients with moderate and severe levels of injury have 635.167 ETB (Standardized coefficient = 0.173, p < 0.001) and 773.621 ETB (Standardized coefficient = 0. 132, p < 0.001) increased costs, respectively, compared to mild level THI patients. Costs for patients ages 31-45 years were 252.504 ETB (Standardized coefficient = - 0.066, p = 0.046) lower than costs for those 5-14 years old. The cost of THI patients increased by 1022.853 ETB for each additional day of hospital length of stay (Standardized coefficient = 0.648, p < 0.001). CONCLUSION: Most expenses of the THI were from direct non-medical cost. Prior health service use, length of stay, level of injury, and age were significant predictors of cost of THI.

The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada.

BACKGROUND: Abusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported. OBJECTIVE: This study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program. PARTICIPANTS AND SETTING: Children aged 0-24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study. METHODS: An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services' perspectives using decision tree models. RESULTS: There were sixty-four AHT events between 2002-2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system. CONCLUSIONS: This study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society.

Emergent and Urgent Craniotomies in Pediatric Patients: Resource Utilization and Cost Analysis.

BACKGROUND: Pediatric neurosurgeons are occasionally tasked with performing surgery expeditiously to preserve a child's neurologic faculties and life. OBJECTIVE: This study examines the etiologies, outcomes, and costs for urgent or emergent craniotomies at a Level I Pediatric Trauma center over a 7-year time period. METHODS: A retrospective review was conducted for each patient who underwent an emergent or urgent craniotomy within 24 hours of presentation between January 2010 and April 2017. Demographic, clinical, and surgical details were recorded for a total of 48 variables. Any readmission within 90 days was analyzed. Hospital charges for each admission and readmission were collected and adjusted for inflation to October 2018 values. RESULTS: Among the 223 children who underwent urgent or emergent craniotomies, the majority were admitted for traumatic injuries (n = 163, 73.1%). The most common traumatic mechanism was fall (n = 51, 22.9%), and the most common non-traumatic cause was tumor (n = 21, 9.4%). Overall, craniotomies were typically performed for hematoma evacuation of one type or combination (n = 115, 51.6%) during off-peak times (n = 178, 79.8%). Seventy-seven (34.5%) subjects experienced 1 or more postoperative events, 22 of whom returned to the operating room. There were 13 (5.8%) and 33 (14.8%) readmissions within 30 days and 90 days of discharge, respectively. Non-trauma patients (compared with trauma patients) and polytrauma (compared with isolated head injury) had greater healthcare needs, resulting in higher charges. CONCLUSION: Most urgent or emergent pediatric craniotomies were performed for the treatment of traumatic injuries involving hematoma evacuation, but non-traumatic patients were more complex requiring greater resources.

Unhelmeted Motorcycle Riders Have Increased Injury Burden: A Need to Revisit Universal Helmet Laws.

BACKGROUND: The aim of this study was to compare hospital outcomes for patients in a motorcycle collision with and without helmet use. The study was conducted as a retrospective analysis of the National Trauma Data Bank's 2013 data set, which included reported data from 100 hospitals across the United States. METHODS: Inclusion criterion for this study is a motorcycle crash involving a driver or passenger. The total number of patients in motorcycle crashes as reported by the National Trauma Data Bank in 2013 was 10,345. Helmet use, hospital stay, ICU and ventilation days, mortality, Glasgow Coma Score, Injury Severity Score, patient payer mix, and complication data were obtained. RESULTS: Patients were divided into two groups: those wearing a helmet (n = 6250) and those without (n = 4095). Patients not wearing a helmet had an increased risk of admission to the ICU (OR = 1.36, P < 0.001, CI 1.25-1.48), requiring ventilation support (OR = 1.55, P < 0.001, CI 1.39-1.72), presenting with a Glasgow Coma Score of eight or below (OR = 2.15, P < 0.001), and in-patient mortality (OR = 2.00, P < 0.001, CI 1.58-2.54). Unhelmeted patients were more likely to have government insurance or be uninsured than those patients wearing a helmet (P < 0.001). CONCLUSIONS: It is not well understood why many states are repealing or have repealed universal helmet laws. Lack of helmet use increases the severity of injury in traumatized patients leading to a substantial financial impact on health care costs. Our analysis suggests the need to revisit the issue regarding laws that require protective headwear while riding motorcycles because of the individual and societal impact. LEVEL OF EVIDENCE: III.

Incidence and severity of head injury hospitalisations in Australian children over a 10-year period.

ISSUE ADDRESSED: Child head injuries can cause life-long disability and are a major cause of mortality globally. The incidence and impact of child head injuries in Australia is unknown. This study aimed to quantify the incidence, characteristics and treatment cost and to identify factors associated with the severity of hospitalisations of head injuries in Australian children. METHODS: Linked hospitalisation and mortality data were used to retrospectively examine hospitalisation trends for head injury in children aged ≤16 years and associated factors, in Australia, from 1 July 2002 to 30 June 2012. RESULTS: There were 164 126 hospitalisations of children for head injury during the 10-year period, commonly male (65.5%), or aged ≤5 years (48.3%). The incidence among children aged <1 year and 1-5 years significantly increased by 1.7% (95% CI 0.9-2.6; P < 0.0001) and 1.5% (95% CI 1.1-1.9; P < 0.0001) annually during the study period, respectively. The most common injury mechanisms across all age groups were falls (45.2%) and road trauma (16.0%). Head injury hospitalisations cost $468.9 million, with the higher costs found for children aged 11-16 years, and for the most severe injuries. CONCLUSION: Head injury hospitalisations cost the Australian health system close to half a billion dollars over a 10-year period, with the most serious injuries resulting in lifelong health implications. SO WHAT?: Targeted health promotion strategies such as the promotion of helmet wearing during scooter use, the introduction of cycleways, and impact absorbing surfaces on playgrounds, need to be implemented to reduce the occurrence of head injuries in children.

Pediatric Abusive Head Trauma: Return to Hospital System in the First Year Post Injury.

BACKGROUND: Abusive head trauma (AHT) may result in costly, long-term sequelae. OBJECTIVE: To describe the burden of AHT on the hospital system within the first year of injury. METHODS: Single institution retrospective evaluation of AHT cases from January 2009 to August 2016. Demographic, clinical (including injury severity graded I-III), and charge data associated with both initial and return hospital visits within 1 yr of injury were extracted. RESULTS: A total of 278 cases of AHT were identified: 60% male, 76% infant, and 54% African-American. Of these 278 cases, 162 (60%) returned to the hospital within the first year, resulting in 676 total visits (an average of 4.2 returns/patient). Grade I injuries were less likely to return than more serious injuries (II and III). The majority were outpatient services (n = 430, 64%); of the inpatient readmissions, neurosurgery was the most likely service to be involved (44%). Neurosurgical procedures accounted for the majority of surgeries performed during both initial admission and readmission (85% and 68%, respectively). Increasing injury severity positively correlated with charges for both the initial admission and returns (P < .001 for both). Total calculated charges, including initial admission and returns, were over $25 million USD. CONCLUSION: AHT has a high potential for return to the hospital system within the first year. Inpatient charges dominate and account for the vast majority of hospital returns and overall charges. A more severe initial injury correlates with increased charges on initial admission and on subsequent hospital return.

A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury.

STUDY OBJECTIVE: To determine the cost-effectiveness of 3 clinical decision rules in comparison to Australian and New Zealand usual care: the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), the Pediatric Emergency Care Applied Research Network (PECARN), and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH). METHODS: A decision analytic model was constructed from the Australian health care system perspective to compare costs and outcomes of the 3 clinical decision rules compared with Australian and New Zealand usual care. The study involved multicenter recruitment from 10 Australian and New Zealand hospitals; recruitment was based on the Australian Pediatric Head Injury Rules Study involving 18,913 children younger than 18 years and with a head injury, and with Glasgow Coma Scale score 13 to 15 on presentation to emergency departments (EDs). We determined the cost-effectiveness of the 3 clinical decision rules compared with usual care. RESULTS: Usual care, CHALICE, PECARN, and CATCH strategies cost on average AUD $6,390, $6,423, $6,433, and $6,457 per patient, respectively. Usual care was more effective and less costly than all other strategies and is therefore the dominant strategy. Probabilistic sensitivity analyses showed that when simulated 1,000 times, usual care dominated all clinical decision rules in 61%, 62%, and 60% of simulations (CHALICE, PECARN, and CATCH, respectively). The difference in cost between all rules was less than $36 (95% confidence interval -$7 to $77) and the difference in quality-adjusted life-years was less than 0.00097 (95% confidence interval 0.0015 to 0.00044). Results remained robust under sensitivity analyses. CONCLUSION: This evaluation demonstrated that the 3 published international pediatric head injury clinical decision rules were not more cost-effective than usual care in Australian and New Zealand tertiary EDs. Understanding the usual care context and the likely cost-effectiveness is useful before investing in implementation of clinical decision rules or incorporation into a guideline.

[Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma]. / Kosten und Erlöse von über den Schockraum eingelieferten Patienten mit leichtem Schädel-Hirn-Trauma.

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. A considerable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2­day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

[Trauma craneal no accidental en niños: costo económico directo de la atención médica en un hospital de tercer nivel].

INTRODUCTION: Abusive head trauma (AHT) is an extreme form of physical abuse that is produced by abruptly shaking an infant or toddler. OBJECTIVE: To describe the direct economic cost of care during hospitalization of 14 children with confirmed diagnosis of AHT in a pediatric hospital. METHOD: Analysis of the cost of disease in patients with AHT attended to between 2001 and 2010. Partial direct economic cost of medical care (days of hospital stay, laboratory tests and imaging studies, surgical procedures and subspecialist consultations) was calculated adjusting for inflation, with year 2001 taken as base year. Patients were classified in three groups (moderate, severe and fatal AHT). Descriptive and sensitivity analysis was carried out. RESULTS: Patients with severe AHT generated higher medical care costs ($105,794.88 ± 33,201.91) in comparison with the group of moderate ($37,012.95, ± 7,154.87) and fatal AHT ($18,595.04 ± 6424.47) (p <0.05). Total cost was $665,467.98 Mexican pesos ($71,249.25 international dollars). CONCLUSIONS: Total cost for the 14 patients was an elevated figure, as in other parts of the world. The direct economic cost is closely related to the severity of the clinical presentation.

INTRODUCCIÓN: El trauma craneal no accidental (TCNA) es una forma extrema de abuso físico que se produce por la sacudida brusca de un lactante o preescolar. OBJETIVO: Describir el costo económico directo de la atención durante la hospitalización de 14 niños con diagnóstico confirmado de TCNA en un hospital pediátrico. MÉTODO: Análisis del costo de la enfermedad en pacientes con TCNA, atendidos entre 2001 y 2010. Se realizó análisis descriptivo y de sensibilidad. Se calculó costo económico directo parcial de la atención médica (días de estancia hospitalaria, exámenes de laboratorio y gabinete, procedimientos quirúrgicos y consultas por subespecialista), ajustado por la inflación, se tomó como año base 2001. Los pacientes se clasificaron en tres grupos: TCNA moderado, severo y fatal. RESULTADOS: Los pacientes con TCNA severo generaron mayor costo en la atención médica ($105 794.88 ± 33 201.91), en comparación con el grupo con TCNA moderado ($37 012.95 ± 7154.87) y fatal ($18 595.04 ± 6424.47) (p < 0.05). El costo total fue de 665 467.98 pesos mexicanos (71 249.25 dólares internacionales). CONCLUSIONES: El costo total de los 14 pacientes fue una cifra elevada como en otras partes del mundo. El costo económico directo se relaciona estrechamente con la gravedad del cuadro clínico.

The estimated cost of surgically managed isolated traumatic head injury secondary to road traffic accidents.

OBJECTIVE Traumatic brain injury due to road traffic accidents occurs mainly in the younger age group in which injury-related disability leads to long-term impact on employment and economic and social consequences across the lifespan. This study was designed to assign a monetary cost (in Malaysian ringgits [RM]) to the treatment of patients with surgically treated isolated traumatic head injury as determined up to 1 year after injury. METHODS Relevant resource items used were identified and valued using the direct measurement of costs method, cost accounting methods, standard unit costs method, fees, charges and/or market prices method. These values were then tabulated to generate the total costs for each patient, via a combination of macro-costing and micro-costing methods. Malaysian currency values were converted to US dollars according to the average conversion rate for the period from January to May 2016: RM1 = US$0.2452. RESULTS This costing study analyzed data from 49 patients. The estimated cost for the 1st year of care for all patients was RM1,471,919.80 (US$360,914.735), with a mean (± SD) cost per case of RM30,039.18 ± 22,986.25 or $7365.61 ± $5636.23. The mean cost of care per case was RM11,041.35 ± 10,936.88 or $2707.34 ± $2681.72 for mild head injury, RM32,550.00 ± 20,998.76 or $7981.26 ± $5148.90 for moderate head injury, and RM36,917.86 ± 23,697.34 or $9052.26 ± $5810.59 for severe head injury. Severe head injury (p = 0.001), sustaining 2 or more intracranial pathologies (p = 0.01), having a poor Glasgow Outcome Scale (GOS) score (GOS score 1-3) (p = 0.02), requiring a tracheostomy (p < 0.001), and contracting pneumonia (p < 0.001) were significantly associated with higher cost. Logistic regression analysis revealed that cost of care increased by RM591.60 or $145.06 per year increment of age (ß = RM591.60, p = 0.05). CONCLUSIONS The mean cost of treatment for traumatic head injury is high compared to the per capita income of RM37,900 in 2016. The cost values generated in this study provide baseline cost estimates that the authors hope will be used as a guide to determine where adequate funding should be allocated to provide timely and appropriate delivery of care.

Effect of clinical decision rules, patient cost and malpractice information on clinician brain CT image ordering: a randomized controlled trial.

BACKGROUND: The frequency of head computed tomography (CT) imaging for mild head trauma patients has raised safety and cost concerns. Validated clinical decision rules exist in the published literature and on-line sources to guide medical image ordering but are often not used by emergency department (ED) clinicians. Using simulation, we explored whether the presentation of a clinical decision rule (i.e. Canadian CT Head Rule - CCHR), findings from malpractice cases related to clinicians not ordering CT imaging in mild head trauma cases, and estimated patient out-of-pocket cost might influence clinician brain CT ordering. Understanding what type and how information may influence clinical decision making in the ordering advanced medical imaging is important in shaping the optimal design and implementation of related clinical decision support systems. METHODS: Multi-center, double-blinded simulation-based randomized controlled trial. Following standardized clinical vignette presentation, clinicians made an initial imaging decision for the patient. This was followed by additional information on decision support rules, malpractice outcome review, and patient cost; each with opportunity to modify their initial order. The malpractice and cost information differed by assigned group to test the any temporal relationship. The simulation closed with a second vignette and an imaging decision. RESULTS: One hundred sixteen of the 167 participants (66.9%) initially ordered a brain CT scan. After CCHR presentation, the number of clinicians ordering a CT dropped to 76 (45.8%), representing a 21.1% reduction in CT ordering (P = 0.002). This reduction in CT ordering was maintained, in comparison to initial imaging orders, when presented with malpractice review information (p = 0.002) and patient cost information (p = 0.002). About 57% of clinicians changed their order during study, while 43% never modified their imaging order. CONCLUSION: This study suggests that ED clinician brain CT imaging decisions may be influenced by clinical decision support rules, patient out-of-pocket cost information and findings from malpractice case review. TRIAL REGISTRATION: NCT03449862 , February 27, 2018, Retrospectively registered.

Lifetime Cost of Abusive Head Trauma at Ages 0-4, USA.

This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids' Inpatient Database, and previous studies. Unit costs were derived from published sources. From society's perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2-9.2 million) for a death. It averages $2.6 million (95% CI $1.0-2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5-16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.

Direct medical costs of motorcycle crashes in Ontario.

BACKGROUND: There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes. METHODS: We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach. RESULTS: We identified 26 831 patients injured in motorcycle crashes and 281 826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale ≥ 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100 000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001). INTERPRETATION: Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety.

Unintentional Head Injury in Children Less than 3 Years of Age: An Insight into Safety Practices in a Developing Country.

Being dependent on caretakers for their safety, children under the age of 3 years are particularly vulnerable to unintentional injury. To identify the circumstances and consequences of head injury in this age group and to assess preventability in a setting of low parental educational levels, we conducted a retrospective cohort study of children less than 3 years of age admitted to hospital with a head injury and in addition categorized the degree of preventability of injury. This study included 109 children, representing a third of head-injured children under the age of 16 years, and 23.4% of these were infants. A significant proportion of head injuries, i.e., 20.18%, were designated "serious" and there was an in-hospital mortality rate of 7.3%. Most of the injuries (80%) occurred in the home and 76% could have been prevented through improved parental supervision and safety measures. We conclude that, in a setting of low maternal education, head injuries in preschoolers largely result from a lack of diligence of the caretakers, presenting opportunities for prevention strategies via a multidimensional approach that integrates safety information into the preexisting national health programs.

Pediatric abusive head trauma and stroke.

OBJECTIVE Despite established risk factors, abusive head trauma (AHT) continues to plague our communities. Cerebrovascular accident (CVA), depicted as areas of hypodensity on CT scans or diffusion restriction on MR images, is a well-known consequence of AHT, but its etiology remains elusive. The authors hypothesize that a CVA, in isolation or in conjunction with other intracranial injuries, compounds the severity of a child's injury, which in turn leads to greater health care utilization, including surgical services, and an increased risk of death. METHODS The authors conducted a retrospective observational study to evaluate data obtained in all children with AHT who presented to Le Bonheur Children's Hospital (LBCH) from January 2009 through August 2016. Demographic, hospital course, radiological, cost, and readmission information was collected. Children with one or more CVA were compared with those without a CVA. RESULTS The authors identified 282 children with AHT, of whom 79 (28%) had one or more CVA. Compared with individuals without a CVA, children with a stroke were of similar overall age (6 months), sex (61% male), and race (56% African-American) and had similar insurance status (81% public). Just under half of all children with a stroke (38/79, 48%) were between 1-6 months of age. Thirty-five stroke patients (44%) had a Grade II injury, and 44 (56%) had a Grade III injury. The majority of stroke cases were bilateral (78%), multifocal (85%), associated with an overlying subdural hematoma (86%), and were watershed/hypoperfusion in morphology (73%). Thirty-six children (46%) had a hemispheric stroke. There were a total of 48 neurosurgical procedures performed on 28 stroke patients. Overall median hospital length of stay (11 vs 3 days), total hospital charges ($13.8 vs $6.6 million), and mean charges per patient ($174,700 vs $32,500) were significantly higher in the stroke cohort as a whole, as well as by injury grade (II and III). Twenty children in the stroke cohort (25%) died as a direct result of their AHT, whereas only 2 children in the nonstroke cohort died (1%). There was a 30% readmission rate within the first 180-day postinjury period for patients in the stroke cohort, and of these, approximately 50% required additional neurosurgical intervention(s). CONCLUSIONS One or more strokes in a child with AHT indicate a particularly severe injury. These children have longer hospital stays, greater hospital charges, and a greater likelihood of needing a neurosurgical intervention (i.e., bedside procedure or surgery). Stroke is such an important predictor of health care utilization and outcome that it warrants a subcategory for both Grade II and Grade III injuries. It should be noted that the word "stroke" or "CVA" should not automatically imply arterial compromise in this population.

Electric bicycle-related injuries presenting to a provincial hospital in China: A retrospective study.

The use of electric bicycles (EBs) in China is growing. In the present study, we aimed to characterize the pattern and outcomes of EB-related injuries presenting to a major general hospital in China.This was a retrospective review of EB-related injuries presenting to Zhejiang Provincial People's Hospital from 2008 to 2011. Cases were identified from medical records according to diagnosis codes. Data captured included demographics, injury characteristics, and outcomes.A total of 3156 cases were reviewed in the present study. There were 1460 cases of traffic accidents, of which 482 cases were EB-related (32.7%). In addition, most of EB-related cases (44.6%) belonged to the 41- to 60-year-old age group. Median injury severity score was 10. Moreover, 34.9% underwent surgery and 24.7% were admitted to intensive care unit. The median hospitalization cost was 14,269 USD. Fracture (56.5%) was the most frequently diagnosed injury type, and head was the most commonly injured body region (31.1%).EB-related injuries have become a major health concern, making up a sizeable proportion of injuries presenting to the emergency department. Therefore, it is necessary to establish injury prevention and strategies for EB road safety. Implementation of policy such as compulsory helmet use, as well as popularization of EB road safety education should be considered to improve the current situation of EB-related injuries in China.