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JAMA Network Open Oct 2023Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911... (Comparative Study)
Comparative Study
IMPORTANCE
Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system.
OBJECTIVE
To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded.
DESIGN, SETTINGS, AND PARTICIPANTS
This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023.
EXPOSURES
Acute painful traumatic injuries including burns.
MAIN OUTCOMES AND MEASURES
Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine.
RESULTS
The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients.
CONCLUSIONS AND RELEVANCE
In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.
Topics: Aged; Female; Humans; Middle Aged; Analgesia; Analgesics, Opioid; Black or African American; Cohort Studies; Emergency Medical Services; Ethnicity; Healthcare Disparities; Ketamine; Minority Groups; Pain; Pain Management; Wounds and Injuries; Male; Adult; Adolescent; Young Adult; Aged, 80 and over; United States; Asian; White; American Indian or Alaska Native; Hispanic or Latino; Native Hawaiian or Other Pacific Islander
PubMed: 37847499
DOI: 10.1001/jamanetworkopen.2023.38070 -
Behavioral and Brain Functions : BBF Oct 2019Traumatic injury (TI) during pregnancy increases the risk for developing neurological disorders in the infants. These disorders are a major concern for the well-being of...
Traumatic injury (TI) during pregnancy increases the risk for developing neurological disorders in the infants. These disorders are a major concern for the well-being of children born after TI during pregnancy. TI during pregnancy may result in preterm labor and delivery, abruptio placentae, and/or fetomaternal hemorrhage. Drosophila melanogaster (fruit fly) is a widely used model to study brain and behavioral disorders in humans. In this study, we analyzed the effects of TI to female fruit flies on the development timing of larvae, social interaction and the behavior of offspring flies. TI to the female flies was found to affect the development of larvae and the behavior of offspring flies. There was a significant increase in the length of larvae delivered by traumatically injured maternal flies as compared to larvae from control maternal flies (without TI). The pupae formation from larvae, and the metamorphosis of pupae to the first generation of flies were faster in the TI group than the control group. Negative geotaxis and distance of the fly to its nearest neighbor are parameters of behavioral assessment in fruit flies. Negative geotaxis significantly decreased in the first generation of both male (p = 0.0021) and female (p = 0.0426) flies. The distance between the first generation of flies to its nearest neighbor was shorter in both male and female offspring flies in the TI group as compared to control group flies. These results indicate that TI to the female flies affected the development of larvae and resulted in early delivery, impaired social interaction and behavioral alterations in the offspring.
Topics: Animals; Behavior, Animal; Developmental Disabilities; Drosophila melanogaster; Female; Larva; Male; Pregnancy; Prenatal Exposure Delayed Effects; Prenatal Injuries; Problem Behavior; Wounds and Injuries
PubMed: 31653253
DOI: 10.1186/s12993-019-0163-1 -
Journal of Pediatric Surgery Apr 2017The implications of childhood obesity on pediatric trauma outcomes are not clearly established. Anthropomorphic data were recently added to the National Trauma Data Bank...
BACKGROUND/PURPOSE
The implications of childhood obesity on pediatric trauma outcomes are not clearly established. Anthropomorphic data were recently added to the National Trauma Data Bank (NTDB) Research Datasets, enabling a large, multicenter evaluation of the effect of obesity on pediatric trauma patients.
METHODS
Children ages 2 to 19years who required hospitalization for traumatic injury were identified in the 2013-2014 NTDB Research Datasets. Age and gender-specific body mass indices (BMI) were calculated. Outcomes included injury patterns, operative procedures, complications, and hospital utilization parameters.
RESULTS
Data from 149,817 pediatric patients were analyzed; higher BMI percentiles were associated with significantly more extremity injuries, and fewer injuries to the head, abdomen, thorax and spine (p values <0.001). On multivariable analysis, higher BMI percentiles were associated with significantly increased likelihood of death, deep venous thrombosis, pulmonary embolus and pneumonia; although there was no difference in risk of overall complications. Obese children also had significantly longer lengths of stay and more frequent ventilator requirement.
CONCLUSIONS
Among children admitted after trauma, increased BMI percentile is associated with increased risk of death and potentially preventable complications. These findings suggest that obese children may require different management than nonobese counterparts to prevent complications.
LEVEL OF EVIDENCE
Level III; prognosis study.
Topics: Adolescent; Body Mass Index; Child; Child, Preschool; Databases, Factual; Female; Hospitalization; Humans; Male; Pediatric Obesity; Pneumonia; Prognosis; Pulmonary Embolism; Respiration, Artificial; Retrospective Studies; Risk Factors; Surgical Procedures, Operative; Trauma Severity Indices; United States; Venous Thrombosis; Wounds and Injuries; Young Adult
PubMed: 27914588
DOI: 10.1016/j.jpedsurg.2016.11.037 -
World Journal of Surgery Jul 2020In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the... (Comparative Study)
Comparative Study
BACKGROUND
In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) of trauma patient were compared to elucidate comprehensive injury characteristics associated with mortality.
METHODS
A retrospective, descriptive analysis of adults (≥ 13 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from February 2008 to May 2018 was performed. Utilizing an emergency department-based trauma surveillance database, univariate and bivariate analysis was performed to compare patient and injury characteristics of pre-hospital and in-hospital deaths. A Poisson multivariate regression was performed, predicting the relative risk of PHD.
RESULTS
Between February 2008 and May 2018, 131,020 adult trauma patients presented to KCH, with 2007 fatalities. Of those patients, 1130 (56.3%) and 877 (43.7%) were PHD and IHD, respectively. The majority were men, with a mean age of 33.4 years (SD 12.1) for PHD and 37.4 years (SD 15.5) for IHD, (p < 0.001). Head injuries (n = 545, 49.2% vs. n = 435, 49.7%) due to assaults (n = 255, 24.7% vs. n = 178, 21.8%) and motor vehicle collisions (MVC) (n = 188, 18.2% vs. n = 173, 21.2%) were the leading cause of both groups (PHD vs. IHD). Transportation to the hospital was primarily police (n = 663, 60.1%) for PHD and ambulance (n = 401, 46.4%) for IHD. Patients who were transported to KCH by the police (RR 1.97, 95% 1.52-2.55, p < 0.001) when compared to transport via minibus had an increased relative risk of PHD. Patients with a head or spine (RR 1.32, 95% CI 1.34-1.53, p < 0.001), chest (RR 1.34, 95% CI 1.11-1.62, p = 0.002) or abdomen and pelvis (RR 1.30, 95% CI 1.14-1.53, p = 0.004) when compared to extremity injury had an increased relative risk of PHD.
CONCLUSIONS
Head injury from assaults and MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police if PHD. Of IHD patients, the majority are transported by ambulance, most often from outside hospitals. Both are consistent with the absence of a pre-hospital system in Malawi. Improving pre-hospital care, with a particular focus on head injury and strategies for vehicular injury prevention within a trauma system, will reduce adult trauma mortality in Malawi.
Topics: Adult; Craniocerebral Trauma; Female; Hospital Mortality; Humans; Malawi; Male; Middle Aged; Retrospective Studies; Risk Factors; Wounds and Injuries; Young Adult
PubMed: 32157403
DOI: 10.1007/s00268-020-05470-w -
Pediatric Critical Care Medicine : a... Jan 2018To determine the rate, etiology, and timing of unplanned and planned hospital readmissions and to identify risk factors for unplanned readmission in children who survive...
OBJECTIVES
To determine the rate, etiology, and timing of unplanned and planned hospital readmissions and to identify risk factors for unplanned readmission in children who survive a hospitalization for trauma.
DESIGN
Multicenter retrospective cohort study of a probabilistically linked dataset from the National Trauma Data Bank and the Pediatric Health Information System database, 2007-2012.
SETTING
Twenty-nine U.S. children's hospitals.
PATIENTS
51,591 children (< 18 yr at admission) who survived more than or equal to a 2-day hospitalization for trauma.
MEASUREMENTS AND MAIN RESULTS
The primary outcome was unplanned readmission within 1 year of discharge from the injury hospitalization. Secondary outcomes included any readmission, reason for readmission, time to readmission, and number of readmissions within 1 year of discharge. The primary exposure groups were isolated traumatic brain injury, both traumatic brain injury and other injury, or nontraumatic brain injury only. We hypothesized a priori that any traumatic brain injury would be associated with both planned and unplanned hospital readmission. We used All Patient Refined Diagnosis Related Groups codes to categorize readmissions by etiology and planned or unplanned. Overall, 4,301/49,982 of the patients (8.6%) with more than or equal to 1 year of observation time were readmitted to the same hospital within 1 year. Many readmissions were unplanned: 2,704/49,982 (5.4%) experienced an unplanned readmission in the first year. The most common reason for unplanned readmission was infection (22%), primarily postoperative or posttraumatic infection (38% of readmissions for infection). Traumatic brain injury was associated with lower odds of unplanned readmission in multivariable analyses. Seizure or RBC transfusion during the index hospitalization were the strongest predictors of unplanned, earlier, and multiple readmissions.
CONCLUSIONS
Many survivors of pediatric trauma experience unplanned, and potentially preventable, hospital readmissions in the year after discharge. Identification of those at highest risk of readmission can guide targeted in-hospital or postdischarge interventions.
Topics: Adolescent; Child; Child, Preschool; Cohort Studies; Databases, Factual; Female; Hospitals, Pediatric; Humans; Logistic Models; Male; Patient Readmission; Retrospective Studies; Risk Factors; United States; Wounds and Injuries
PubMed: 29210926
DOI: 10.1097/PCC.0000000000001383 -
Chinese Journal of Traumatology =... Mar 2021Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic... (Review)
Review
Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.
Topics: ADAMTS13 Protein; Atypical Hemolytic Uremic Syndrome; Disseminated Intravascular Coagulation; Female; Humans; Male; Pregnancy; Surgeons; Thrombotic Microangiopathies; Wounds and Injuries
PubMed: 33518399
DOI: 10.1016/j.cjtee.2021.01.004 -
Critical Care (London, England) May 2013Statins, in addition to their lipid-lowering properties, have anti-inflammatory actions. The aim of this review is to evaluate the effect of pre-injury statin use, and... (Review)
Review
Statins, in addition to their lipid-lowering properties, have anti-inflammatory actions. The aim of this review is to evaluate the effect of pre-injury statin use, and statin treatment following injury. MEDLINE, EMBASE, and CENTRAL databases were searched to January 2012 for randomised and observational studies of statins in trauma patients in general, and in patients who have suffered traumatic brain injury, burns, and fractures. Of 985 identified citations, 7 (4 observational studies and 3 randomised controlled trials (RCTs)) met the inclusion criteria. Two studies (both observational) were concerned with trauma patients in general, two with patients who had suffered traumatic brain injury (one observational, one RCT), two with burns patients (one observational, one RCT), and one with fracture healing (RCT). Two of the RCTs relied on surrogate outcome measures. The observational studies were deemed to be at high risk of confounding, and the RCTs at high risk of bias. Three of the observational studies suggested improvements in a number of clinical outcomes in patients taking statins prior to injury (mortality, infection, and septic shock in burns patients; mortality in trauma patients in general; mortality in brain injured patients) whereas one, also of trauma patients in general, showed no difference in mortality or infection, and an increased risk of multi-organ failure. Two of three RCTs on statin treatment in burns patients and brain injured patients showed improvements in E-selectin levels and cognitive function. The third, of patients with radial fractures, showed no acceleration in fracture union. In conclusion, there is some evidence that pre-injury statin use and post-injury statin treatment may have a beneficial effect in patients who have suffered general trauma, traumatic brain injury, and burns. However, these studies are at high risk of confounding and bias, and should be regarded as 'hypothesisgenerating'. A well-designed RCT is required to determine the therapeutic efficacy in improving outcomes in this patient population.
Topics: Drug Administration Schedule; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Observational Studies as Topic; Randomized Controlled Trials as Topic; Wounds and Injuries
PubMed: 23751018
DOI: 10.1186/cc12499 -
Scientific Reports Nov 2021Abbreviated Injury Scale (AIS)-based systems such as injury severity score (ISS), exponential injury severity score (EISS), trauma mortality prediction model (TMPM), and...
Abbreviated Injury Scale (AIS)-based systems such as injury severity score (ISS), exponential injury severity score (EISS), trauma mortality prediction model (TMPM), and injury mortality prediction (IMP), classify anatomical injuries with limited accuracy. The widely accepted alternative, trauma and injury severity score (TRISS), improves the prediction rate by combining an anatomical index of ISS, physiological index (the Revised Trauma Score, RTS), and the age of patients. The study introduced the traumatic injury mortality prediction (TRIMP) with the inclusion of extra clinical information and aimed to compare the ability against the TRISS as predictors of survival. The hypothesis was that TRIMP would outperform TRISS in prediction power by incorporating clinically available data. This was a retrospective cohort study where a total of 1,198,885 injured patients hospitalized between 2012 and 2014 were subset from the National Trauma Data Bank (NTDB) in the United States. A TRIMP model was computed that uses AIS 2005 (AIS_05), physiological reserve and physiological response indicators. The results were analysed by examining the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow (HL) statistic, and the Akaike information criterion. TRIMP gave both significantly better discrimination (AUC, 0.964; 95% confidence interval (CI), 0.962 to 0.966 and AUC, 0.923; 95% CI, 0.919 to 0.926) and calibration (HL, 14.0; 95% CI, 7.7 to 18.8 and HL, 411; 95% CI, 332 to 492) than TRISS. Similar results were found in statistical comparisons among different body regions. TRIMP was superior to TRISS in terms of accurate of mortality prediction, TRIMP is a new and feasible scoring method in trauma research and should replace the TRISS.
Topics: Adult; Aged; Female; Humans; Injury Severity Score; Male; Middle Aged; Models, Statistical; Retrospective Studies; United States; Wounds and Injuries
PubMed: 34741125
DOI: 10.1038/s41598-021-98558-9 -
Injury Mar 2011Traumatic injury is an important public health problem secondary to high levels of morbidity and mortality. Injured survivors face several physical, emotional, and... (Review)
Review
Traumatic injury is an important public health problem secondary to high levels of morbidity and mortality. Injured survivors face several physical, emotional, and financial repercussions that can significantly impact their lives as well as their family. Depression and posttraumatic stress disorder (PTSD) are the most common psychiatric sequelae associated with traumatic injury. Factors affecting the prevalence of these psychiatric symptoms include: concomitant TBI, the timing of assessment of depression and PTSD, the type of injury, premorbid, sociodemographic, and cultural factors, and co-morbid medical conditions and medication side effects. The appropriate assessment of depression and PTSD is critical to an understanding of the potential consequences of these disorders as well as the development of appropriate behavioural and pharmacological treatments. The reliability and validity of screening instruments and structured clinical interviews used to assess depression and PTSD must be considered. Common self-report instruments and structured clinical interviews used to assess depression and PTSD and their reliability and validity are described. Future changes in diagnostic criteria for depression and PTSD and recent initiatives by the National Institute of Health regarding patient-reported outcomes may result in new methods of assessing these psychiatric sequelae of traumatic injury.
Topics: Checklist; Depressive Disorder, Major; Diagnostic and Statistical Manual of Mental Disorders; Female; Humans; Male; Outcome and Process Assessment, Health Care; Severity of Illness Index; Stress Disorders, Post-Traumatic; Wounds and Injuries
PubMed: 21216400
DOI: 10.1016/j.injury.2010.11.045 -
Neuropsychology Feb 2018This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or...
OBJECTIVE
This prospective longitudinal study investigated sleep disturbance (SD) and internalizing problems after traumatic injury, including traumatic brain injury (TBI) or extracranial/bodily injury (EI) in children and adolescents, relative to typically developing (TD) children. We also examined longitudinal relations between SD and internalizing problems postinjury.
METHOD
Participants (N = 87) ages 8-15 included youth with TBI, EI, and TD children. Injury groups were recruited from a Level 1 trauma center after sustaining vehicle-related injuries. Parent-reported SD and internalizing problems were assessed at preinjury/baseline, and 6 and 12 months postinjury. Linear mixed models evaluated the relation of group and time of assessment on outcomes.
RESULTS
Controlling for age, the combined traumatic injury group experienced significantly higher postinjury levels of SD (p = .042) and internalizing problems (p = .024) than TD children; however, TBI and EI injury groups did not differ from each other. Injury severity was positively associated with SD in the EI group only, but in both groups SD was associated with additional postinjury sequelae, including fatigue and externalizing behavior problems. Internalizing problems predicted subsequent development of SD but not vice versa. The relation between injury and SD 1 year later was consistent with mediation by internalizing problems at 6 months postinjury.
CONCLUSIONS
Children with both types of traumatic injury demonstrated higher SD and internalizing problems than healthy children. Internalizing problems occurring either prior to or following pediatric injury may be a risk factor for posttraumatic SD. Consequently, internalizing problems may be a promising target of intervention to improve both SD and related adjustment concerns. (PsycINFO Database Record
Topics: Adolescent; Brain Injuries, Traumatic; Child; Child Behavior Disorders; Female; Humans; Longitudinal Studies; Male; Mental Fatigue; Motor Vehicles; Pain; Prospective Studies; Sexual Maturation; Sleep Wake Disorders; Wounds and Injuries
PubMed: 29528681
DOI: 10.1037/neu0000420