RESUMEN

BACKGROUND: The need for evidence to inform interventions to prevent mass shootings (MS) in the USA has never been greater. METHODS: Data were abstracted from the Gun Violence Archive, an independent online database of US gun violence incidents. Descriptive analyses consisted of individual-level epidemiology of victims, suspected shooters and weapons involved, trends and county-level choropleths of population-level incident and fatality rates. Counties with and without state-level assault weapons bans (AWB) were compared, and we conducted a multivariable negative binomial model controlling for county-level social fragmentation, median age and number of gun-related homicides for the association of state-level AWB with aggregate county MS fatalities. RESULTS: 73.3% (95% CI 72.1 to 74.5) of victims and 97.2% (95% CI 96.3 to 98.3) of shooters were males. When compared with incidents involving weapons labelled 'handguns', those involving a weapon labelled AR-15 or AK-47 were six times more likely to be associated with case-fatality rates greater than the median (OR=6.1, 95% CI 2.3 to 15.8, p<0.00001). MS incidents were significantly more likely to occur on weekends and during summer months. US counties in states without AWB had consistently higher MS rates throughout the study period (p<0.0001), and the slope for increase over time was significantly lower in counties with AWB (beta=-0.11, p=0.01). In a multivariable negative binomial model, counties in states with AWB were associated with a 41% lower incidence of MS fatalities (OR=0.58, 95% CI 0.37 to 0.97, p=0.02). CONCLUSIONS: Counties located in states with AWB were associated with fewer MS fatalities between 2014 and 2022.

RESUMEN

BACKGROUND: Understanding how substance use is associated with severe crash injuries may inform emergency care preparedness. OBJECTIVES: This study aims to assess the association of substance use and crash injury severity at all times of the day and during rush (6-9 AM; 3-7 PM) and non-rush-hours. Further, this study assesses the probabilities of occurrence of low acuity, emergent, and critical injuries associated with substance use. METHODS: Crash data were extracted from the 2019 National Emergency Medical Services Information System. The outcome variable was non-fatal crash injury, assessed on an ordinal scale: critical, emergent, low acuity. The predictor variable was the presence of substance use (alcohol or illicit drugs). Age, gender, injured part, revised trauma score, the location of the crash, the road user type, and the geographical region were included as potential confounders. Partially proportional ordinal logistic regression was used to assess the unadjusted and adjusted odds of critical and emergent injuries compared to low acuity injury. RESULTS: Substance use was associated with approximately two-fold adjusted odds of critical and emergent injuries compared to low acuity injury at all times of the day and during the rush and non-rush hours. Although the proportion of substance use was higher during the non-rush hour period, the interaction effect of rush hour and substance use resulted in higher odds of critical and emergent injuries compared to low acuity injury. CONCLUSION: Substance use is associated with increased odds of critical and emergent injury severity. Reducing substance use-related crash injuries may reduce adverse crash injuries.

Asunto(s)

Servicios Médicos de Urgencia , Trastornos Relacionados con Sustancias , Heridas y Lesiones , Accidentes de Tránsito , Humanos , Modelos Logísticos , Probabilidad , Trastornos Relacionados con Sustancias/epidemiología , Estados Unidos/epidemiología , Heridas y Lesiones/epidemiología

RESUMEN

BACKGROUND: Alcohol and other drugs (AOD) increase the risk of traumatic injury occurring, but data suggest a protective benefit in preventing trauma-related mortality. The objective of this study is to describe the epidemiology of AOD-related traumatic injury in the US over a recent 7 year period and assess the interaction of traumatic injury and AOD on pre-admission fatality on both an additive scale using incidence contrasts and on a statistical multiplicative scale using survey-adjusted logistic regression. METHODS: Using the National Emergency Department Sample (NEDS), we describe the epidemiology of alcohol and substance-related emergency department traumatic injury over a recent period. AOD-related injury was assessed using survey-adjusted counts and means. Ratio estimates and differences were calculated using simulations based on survey-adjusted counts and standard errors. Differences in trends over time were evaluated by comparing the slopes of linear regression equations with year as the predictor variable. RESULTS: Alcohol and substance-related emergency department injury discharges increased 9.8 % during the study period. There was a statistically significant interaction between traumatic injury death and AOD on both an additive scale and multiplicative scale. (Odds Ratio for interaction term = 1.76, 95 % CI = 1.53, 2.03). CONCLUSIONS: AOD use does not provide a protective benefit in the setting of trauma, but rather is an important contributor to traumatic injury mortality.

Asunto(s)

Servicio de Urgencia en Hospital , Preparaciones Farmacéuticas , Etanol , Humanos , Incidencia , Oportunidad Relativa , Estados Unidos/epidemiología

RESUMEN

Importance: An important consequence of cannabis legalization is the potential increase in the number of cannabis-impaired drivers on roads, which may result in higher rates of traffic-related injuries and fatalities. To date, limited information about the effects of recreational cannabis laws (RCLs) on traffic fatalities is available. Objective: To estimate the extent to which the implementation of RCLs is associated with traffic fatalities in Colorado and Washington State. Design, Setting, and Participants: This ecological study used a synthetic control approach to examine the association between RCLs and changes in traffic fatalities in Colorado and Washington State in the post-RCL period (2014-2017). Traffic fatalities data were obtained from the Fatality Analysis Reporting System from January 1, 2005, to December 31, 2017. Data from Colorado and Washington State were compared with synthetic controls. Data were analyzed from January 1, 2005, to December 31, 2017. Main Outcome(s) and Measures: The primary outcome was the rate of traffic fatalities. Sensitivity analyses were performed (1) excluding neighboring states, (2) excluding states without medical cannabis laws (MCLs), and (3) using the enactment date of RCLs to define pre-RCL and post-RCL periods instead of the effective date. Results: Implementation of RCLs was associated with increases in traffic fatalities in Colorado but not in Washington State. The difference between Colorado and its synthetic control in the post-RCL period was 1.46 deaths per 1 billion vehicle miles traveled (VMT) per year (an estimated equivalent of 75 excess fatalities per year; probability = 0.047). The difference between Washington State and its synthetic control was 0.08 deaths per 1 billion VMT per year (probability = 0.674). Results were robust in most sensitivity analyses. The difference between Colorado and synthetic Colorado was 1.84 fatalities per 1 billion VMT per year (94 excess deaths per year; probability = 0.055) after excluding neighboring states and 2.16 fatalities per 1 billion VMT per year (111 excess deaths per year; probability = 0.063) after excluding states without MCLs. The effect was smaller when using the enactment date (24 excess deaths per year; probability = 0.116). Conclusions and Relevance: This study found evidence of an increase in traffic fatalities after the implementation of RCLs in Colorado but not in Washington State. Differences in how RCLs were implemented (eg, density of recreational cannabis stores), out-of-state cannabis tourism, and local factors may explain the different results. These findings highlight the importance of RCLs as a factor that may increase traffic fatalities and call for the identification of policies and enforcement strategies that can help prevent unintended consequences of cannabis legalization.

Asunto(s)

Accidentes de Tránsito/mortalidad , Legislación de Medicamentos , Uso de la Marihuana/legislación & jurisprudencia , Accidentes de Tránsito/estadística & datos numéricos , Colorado , Humanos , Washingtón

RESUMEN

This study evaluated the safety of early anti-factor Xa assay-guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay-guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.

Asunto(s)

Anticoagulantes/administración & dosificación , Lesiones Traumáticas del Encéfalo/complicaciones , Enoxaparina/administración & dosificación , Tromboembolia Venosa/prevención & control , Enfermedad Aguda , Adulto , Anciano , Anticoagulantes/efectos adversos , Quimioprevención , Enoxaparina/efectos adversos , Inhibidores del Factor Xa/sangre , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tiempo de Tratamiento , Índices de Gravedad del Trauma

RESUMEN

OBJECTIVE: Protected bike lanes separated from the roadway by physical barriers are relatively new in the United States. This study examined the risk of collisions or falls leading to emergency department visits associated with bicycle facilities (e.g., protected bike lanes, conventional bike lanes demarcated by painted lines, sharrows) and other roadway characteristics in three U.S. cities. METHODS: We prospectively recruited 604 patients from emergency departments in Washington, DC; New York City; and Portland, Oregon during 2015-2017 who fell or crashed while cycling. We used a case-crossover design and conditional logistic regression to compare each fall or crash site with a randomly selected control location along the route leading to the incident. We validated the presence of site characteristics described by participants using Google Street View and city GIS inventories of bicycle facilities and other roadway features. RESULTS: Compared with cycling on lanes of major roads without bicycle facilities, the risk of crashing or falling was lower on conventional bike lanes (adjusted OR = 0.53; 95 % CI = 0.33, 0.86) and local roads with (adjusted OR = 0.31; 95 % CI = 0.13, 0.75) or without bicycle facilities or traffic calming (adjusted OR = 0.39; 95 % CI = 0.23, 0.65). Protected bike lanes with heavy separation (tall, continuous barriers or grade and horizontal separation) were associated with lower risk (adjusted OR = 0.10; 95 % CI = 0.01, 0.95), but those with lighter separation (e.g., parked cars, posts, low curb) had similar risk to major roads when one way (adjusted OR = 1.19; 95 % CI = 0.46, 3.10) and higher risk when they were two way (adjusted OR = 11.38; 95 % CI = 1.40, 92.57); this risk increase was primarily driven by one lane in Washington. Risk increased in the presence of streetcar or train tracks relative to their absence (adjusted OR = 26.65; 95 % CI = 3.23, 220.17), on downhill relative to flat grades (adjusted OR = 1.92; 95 % CI = 1.38, 2.66), and when temporary features like construction or parked cars blocked the cyclist's path relative to when they did not (adjusted OR = 2.23; 95 % CI = 1.46, 3.39). CONCLUSIONS: Certain bicycle facilities are safer for cyclists than riding on major roads. Protected bike lanes vary in how well they shield riders from crashes and falls. Heavier separation, less frequent intersections with roads and driveways, and less complexity appear to contribute to reduced risk in protected bike lanes. Future research should systematically examine the characteristics that reduce risk in protected lanes to guide design. Planners should minimize conflict points when choosing where to place protected bike lanes and should implement countermeasures to increase visibility at these locations when they are unavoidable.

RESUMEN

BACKGROUND: Assessing aspects of intersections that may affect the risk of pedestrian injury is critical to developing child pedestrian injury prevention strategies, but visiting intersections to inspect them is costly and time-consuming. Several research teams have validated the use of Google Street View to conduct virtual neighborhood audits that remove the need for field teams to conduct in-person audits. METHODS: We developed a 38-item virtual audit instrument to assess intersections for pedestrian injury risk and tested it on intersections within 700 m of 26 schools in New York City using the Computer-assisted Neighborhood Visual Assessment System (CANVAS) with Google Street View imagery. RESULTS: Six trained auditors tested this instrument for inter-rater reliability on 111 randomly selected intersections and for test-retest reliability on 264 other intersections. Inter-rater kappa scores ranged from -0.01 to 0.92, with nearly half falling above 0.41, the conventional threshold for moderate agreement. Test-retest kappa scores were slightly higher than but highly correlated with inter-rater scores (Spearman rho = 0.83). Items that were highly reliable included the presence of a pedestrian signal (K = 0.92), presence of an overhead structure such as an elevated train or a highway (K = 0.81), and intersection complexity (K = 0.76). CONCLUSIONS: Built environment features of intersections relevant to pedestrian safety can be reliably measured using a virtual audit protocol implemented via CANVAS and Google Street View.

Asunto(s)

Entorno Construido , Sistemas de Información Geográfica , Peatones , Características de la Residencia , Seguridad , Entorno Construido/estadística & datos numéricos , Sistemas de Información Geográfica/instrumentación , Humanos , Ciudad de Nueva York , Reproducibilidad de los Resultados , Características de la Residencia/estadística & datos numéricos , Heridas y Lesiones/prevención & control

RESUMEN

BACKGROUND: Powered, two-wheeled transportation devices like electric bicycles (E-bikes) and scooters are increasingly popular, but little is known about their relative injury risk compared to pedal operated bicycles. METHODS: Descriptive and comparative analysis of injury patterns and trends associated with E-bikes, powered scooters and pedal bicycles from 2000 to 2017 using the US National Electronic Injury Surveillance System. RESULTS: While persons injured using E-bikes were more likely to suffer internal injuries (17.1%; 95% CI 5.6 to 28.6) and require hospital admission (OR=2.8, 95% CI 1.3 to 6.1), powered scooter injuries were nearly three times more likely to result in a diagnosis of concussion (3% of scooter injuries vs 0.5% of E-bike injuries). E-bike-related injuries were also more than three times more likely to involve a collision with a pedestrian than either pedal bicycles (OR=3.3, 95% CI 0.5 to 23.6) or powered scooters (OR=3.3, 95% CI 0.3 to 32.9), but there was no evidence that powered scooters were more likely than bicycles to be involved in a collision with a pedestrian (OR=1.0, 95% CI 0.3 to 3.1). While population-based rates of pedal bicycle-related injuries have been decreasing, particularly among children, reported E-bike injuries have been increasing dramatically particularly among older persons. CONCLUSIONS: E-bike and powered scooter use and injury patterns differ from more traditional pedal operated bicycles. Efforts to address injury prevention and control are warranted, and further studies examining demographics and hospital resource utilisation are necessary.

Asunto(s)

Conmoción Encefálica , Peatones , Accidentes de Tránsito , Anciano , Anciano de 80 o más Años , Ciclismo , Niño , Hospitalización , Humanos

RESUMEN

BACKGROUND: Elderly patients with Traumatic Brain Injury (TBI) are frequently transferred to designated Trauma Centers (TC). We hypothesized that TC transfer is associated with improved outcomes. METHODS: Retrospective study utilizing the National Trauma Databank. Demographics, injury and outcomes data were abstracted. Patients were dichotomized by transfer to a designated level I/II TC vs. not. Multivariate regression was used to derive the adjusted primary outcome, mortality, and secondary outcomes, complications and discharge disposition. RESULTS: 19,664 patients were included, with a mean age of 78.1 years. 70% were transferred to a level I/II TC. Transferred patients had a higher ISS (12 vs. 10, p < 0.001). Mortality was significantly lower in patients transferred to level I/II TCs (5.6% vs. 6.2%, Adjusted Odds Ratio (AOR) 0.84, p = 0.011), as was the likelihood of discharge to skilled nursing facilities (26.4% vs. 30.2%, AOR 0.80, p < 0.001). CONCLUSIONS: Elderly patients with mild TBI transferred to level I/II TCs have improved outcomes. Which patients with mild TBI require level I/II TC care should be examined prospectively.

Asunto(s)

Conmoción Encefálica/mortalidad , Transferencia de Pacientes/estadística & datos numéricos , Centros Traumatológicos , Factores de Edad , Anciano , Contusión Encefálica/mortalidad , Comorbilidad , Conjuntos de Datos como Asunto , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Alta del Paciente , Estudios Retrospectivos , Instituciones de Cuidados Especializados de Enfermería/estadística & datos numéricos , Fracturas Craneales/mortalidad , Estados Unidos/epidemiología

RESUMEN

BACKGROUND: Despite substantial progress, motor vehicle crashes remain a leading killer of US children. Previously, we documented significant positive impacts of Safe Routes to School interventions on school-age pedestrian and pedalcyclist crashes. OBJECTIVE: To expand our analysis of US trends in motor vehicle crashes involving school-age pedestrians and pedalcyclists, exploring heterogeneity by age and geography. METHODS: We obtained recent police-reported crash data from 26 states, calculating population rates of pedestrian and pedalcyclist crashes, crash fatality rates and pedestrian commuter-adjusted crash rates ('pedestrian danger index') for school-age children as compared with other age groups. We estimated national and statewide trends by age, injury status, day and travel hour using hierarchical linear modeling. RESULTS: School-age children accounted for nearly one in three pedestrians and one in two pedalcyclists struck in motor vehicle crashes from 2000 to 2014. Yet, the rates of these crashes declined 40% and 53%, respectively, over that time, on average, even as adult rates rose. Average crash rates varied geographically from 24.4 to 100.8 pedestrians and 15.6 to 56.7 pedalcyclists struck per 100 000 youth. Crash rates and fatality rates were inversely correlated. CONCLUSIONS: Despite recent increases in adult pedestrian crashes, school-age and younger pedestrians experienced ongoing declines in motor vehicle crashes through 2014 across the USA. There was no evidence of displacement in crash severity; declines were observed in all outcomes. The growing body of state crash data resources can present analytic challenges but also provides unique insights into national and local pedestrian crash trends for all crash outcomes.

Asunto(s)

Peatones , Heridas y Lesiones , Accidentes de Tránsito , Adolescente , Niño , Análisis por Conglomerados , Humanos , Policia , Instituciones Académicas , Estados Unidos

RESUMEN

BACKGROUND: Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection. OBJECTIVES: The objective of this study was to assess whether ETs performed at Level I trauma centers (TC) are associated with improved survival. METHODS: This was a retrospective study utilizing the National Trauma Databank 2014-2015. We included all thoracotomies performed within 1 h of hospital arrival. Patients were stratified according to TC designation level. Patient demographics, outcomes, and center characteristics were compared. We conducted multivariable regression with survival as the outcome. RESULTS: There were 3183 ETs included in this study; 2131 (66.9%) were performed at Level I TCs. Patients treated at Level I and non-Level I TCs had similar median injury severity scores, as well as signs of life and systolic blood pressures on admission. Patients treated at Level I TCs had significantly higher survival rates (21.6% vs. 16.3%, p < 0.001), with 40% greater odds of survival after controlling for injury-specific factors and emergency medical services transportation time (adjusted odds ratio 1.40, 95% confidence interval 1.04-1.89, p = 0.03). Penetrating injuries had 23.1% survival after ET vs. 12.9% for blunt injuries (adjusted odds ratio 1.86, 95% confidence interval 1.37-2.53, p < 0.001). CONCLUSIONS: ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients.

Asunto(s)

Toracotomía/normas , Centros Traumatológicos/estadística & datos numéricos , Adulto , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , Toracotomía/métodos , Toracotomía/mortalidad , Centros Traumatológicos/organización & administración

RESUMEN

BACKGROUND: Traumatic injury is the leading cause of paediatric morbidity and mortality in the USA. We present updated national data on emergency department (ED) discharges for traumatic injury for a recent 7-year period. METHODS: We conducted a descriptive epidemiological analysis of the Nationwide Emergency Department Sample Survey, the largest and most comprehensive database in the USA, for 2006-2012. Among children and adolescents, we tracked changes in injury mechanism and severity, cost of care, injury intent and the role of trauma centres. RESULTS: There was an 8.3% (95% CI 7.7 to 8.9) decrease in the annual number of ED visits for traumatic injury in children and adolescents over the study period, from 8 557 904 (SE=5861) in 2006 to 7 846 912 (SE=5191) in 2012. The case-fatality rate was 0.04% for all injuries and 3.2% for severely injured children. Children and adolescents with high-mortality injury mechanisms were more than three times more likely to be treated at a level 1 trauma centre (OR=3.5, 95% CI 3.3 to 3.7), but were more no more likely to die (OR=0.96, 95% CI 0.93 to 1.00). Traumatic brain injury diagnoses increased 22.2% (95% CI 20.6 to 23.9) during the study period. Intentional assault accounted for 3% (SE=0.1) of all child and adolescent ED injury discharges and 7.2% (SE=0.3) of discharges among 15-19 year-olds. There was an 11.3% (95% CI 10.0 to 12.6) decline in motor vehicle injuries from 2009 to 2012. The total cost of care was $23 billion (SE=0.01), a 78% increase from 2006 to 2012. CONCLUSIONS: This analysis presents a recent portrait of paediatric trauma across the USA. These analyses indicate the important role and value of trauma centre care for injured children and adolescents, and that the most common causes and mechanisms of injury are preventable.

Asunto(s)

Servicio de Urgencia en Hospital/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Adolescente , Distribución por Edad , Niño , Preescolar , Bases de Datos Factuales , Femenino , Investigación sobre Servicios de Salud , Humanos , Lactante , Puntaje de Gravedad del Traumatismo , Masculino , Estudios Retrospectivos , Distribución por Sexo , Estados Unidos/epidemiología , Heridas y Lesiones/terapia

RESUMEN

BACKGROUND: Firearm-related injuries cause significant morbidity and mortality in the United States (US), consuming resources and fueling political and public health discourse. Most analyses of firearm injuries are based on fatality statistics. Here, we describe the epidemiology of firearm injuries presenting to US emergency departments (EDs). METHODS: We performed a retrospective study of the Healthcare Cost and Utilization Program Nationwide Emergency Department Survey (NEDS) from 2009 to 2012. NEDS is the largest all-payer ED survey in the US containing approximately 30 million annual records. Results include survey-adjusted counts, proportions, means, and rates, and confidence intervals of age-stratified ED discharges for firearm injuries. RESULTS: There were 71,111 (se = 613) ED discharges for firearm injuries in 2009; the absolute number increased 3.9% (se = 1.2) to 75,559 (se = 610) in 2012. 18-to-44-year-olds accounted for the largest proportion of total injuries with 52,187 (se = 527) in 2009 and 56,644 (se = 528) in 2012-a 7.2% (se = 1.6) relative rate increase and an absolute increase of 3.3/100,000 (se = 0.7). Firearm injuries among children < 5-years-old increase 16%, and 19% among children 5-to-9-years-old. 136,112 (se = 761)-or 48.2%-of those injured were treated and discharged home without admission; 106,927 (se = 755) were admitted. Firearm deaths represented one-third of all trauma mortality. Three-quarters of those injured resided in neighborhoods with median incomes below $49,250. CONCLUSIONS: Firearm injuries increased from 2009 to 2012, driven by adults aged 18-to-44-years-old, and disproportionately impacting lower socioeconomic communities. Injuries also increased among young children. Firearm injuries remain a continued public health challenge, and a significant source of ED morbidity and mortality.

RESUMEN

BACKGROUND: Between 1990 and 2003, there were 668 subway-related fatalities in New York City. However, subway-related trauma remains an understudied area of injury-related morbidity and mortality. OBJECTIVE: The objective of this study was to characterize the injuries and events leading up to the injuries of all patients admitted after subway-related trauma. METHODS: We conducted a retrospective case series of subway-related trauma at a Level I trauma center from 2001 to 2016. Descriptive epidemiology of patient demographics, incident details, injuries, and outcomes were analyzed. RESULTS: Over 15 years, 254 patients were admitted for subway-related trauma. The mean (standard error of the mean) age was 41 (1.0) years, 80% were male (95% confidence interval [CI] 74-84%) and median Injury Severity Score was 14 (interquartile range [IQR] 5-24). The overall case-fatality rate was 10% (95% CI 7-15%). The most common injuries were long-bone fractures, intracranial hemorrhage, and traumatic amputations. Median length of stay was 6 days (IQR 1-18 days). Thirty-seven percent of patients required surgical intervention. At the time of injury, 55% of patients (95% CI 49-61%) had a positive urine drug or alcohol screen, 16% (95% CI 12-21%) were attempting suicide, and 39% (95% CI 33-45%) had a history of psychiatric illness. CONCLUSIONS: Subway-related trauma is associated with a high case-fatality rate. Alcohol or drug intoxication and psychiatric illness can increase the risk of this type of injury.

Asunto(s)

Salud Pública/normas , Vías Férreas/estadística & datos numéricos , Salud Urbana/normas , Heridas y Lesiones/etiología , Adulto , Consumo de Bebidas Alcohólicas/efectos adversos , Consumo de Bebidas Alcohólicas/psicología , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York , Vías Férreas/instrumentación , Estudios Retrospectivos , Centros Traumatológicos/organización & administración , Centros Traumatológicos/estadística & datos numéricos

RESUMEN

BACKGROUND: Animals exposed to anesthetics during specific age periods of brain development experience neurotoxicity, with neurodevelopmental changes subsequently observed during adulthood. The corresponding vulnerable age in children, however, is unknown. METHODS: An observational cohort study was performed using a longitudinal dataset constructed by linking individual-level Medicaid claims from Texas and New York from 1999 to 2010. This dataset was evaluated to determine whether the timing of exposure to anesthesia ≤5 years of age for a single common procedure (pyloromyotomy, inguinal hernia, circumcision outside the perinatal period, or tonsillectomy and/or adenoidectomy) is associated with increased subsequent risk of diagnoses for any mental disorder, or specifically developmental delay (DD) such as reading and language disorders, and attention deficit hyperactivity disorder (ADHD). Exposure to anesthesia and surgery was evaluated in 11 separate age at exposure categories: ≤28 days old, >28 days and ≤6 months, >6 months and ≤1 year, and 6-month age intervals between >1 year old and ≤5 years old. For each exposed child, 5 children matched on propensity score calculated using sociodemographic and clinical covariates were selected for comparison. Cox proportional hazards models were used to measure the hazard ratio of a mental disorder diagnosis associated with exposure to surgery and anesthesia. RESULTS: A total of 38,493 children with a single exposure and 192,465 propensity score-matched children unexposed before 5 years of age were included in the analysis. Increased risk of mental disorder diagnosis was observed at all ages at exposure with an overall hazard ratio of 1.26 (95% confidence interval [CI], 1.22-1.30), which did not vary significantly with the timing of exposure. Analysis of DD and ADHD showed similar results, with elevated hazard ratios distributed evenly across all ages, and overall hazard ratios of 1.26 (95% CI, 1.20-1.32) for DD and 1.31 (95% CI, 1.25-1.37) for ADHD. CONCLUSIONS: Children who undergo minor surgery requiring anesthesia under age 5 have a small but statistically significant increased risk of mental disorder diagnoses and DD and ADHD diagnoses, but the timing of the surgical procedure does not alter the elevated risks. Based on these findings, there is little support for the concept of delaying a minor procedure to reduce long-term neurodevelopmental risks of anesthesia in children. In evaluating the influence of age at exposure, the types of procedures included may need to be considered, as some procedures are associated with specific comorbid conditions and are only performed at certain ages.

Asunto(s)

Anestesia General/efectos adversos , Trastornos del Neurodesarrollo/diagnóstico , Trastornos del Neurodesarrollo/etiología , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiología , Factores de Edad , Anestesia General/tendencias , Preescolar , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Estudios Longitudinales , Masculino , Trastornos del Neurodesarrollo/psicología , Complicaciones Posoperatorias/psicología , Estudios Retrospectivos

RESUMEN

BACKGROUND: As an important indicator of mobility, driving confers a host of social and health benefits to older adults. Despite the importance of safe mobility as the population ages, longitudinal data are lacking about the natural history and determinants of driving safety in older adults. METHODS: The Longitudinal Research on Aging Drivers (LongROAD) project is a multisite prospective cohort study designed to generate empirical data for understanding the role of medical, behavioral, environmental and technological factors in driving safety during the process of aging. RESULTS: A total of 2990 active drivers aged 65-79 years at baseline have been recruited through primary care clinics or health care systems in five study sites located in California, Colorado, Maryland, Michigan, and New York. Consented participants were assessed at baseline with standardized research protocols and instruments, including vehicle inspection, functional performance tests, and "brown-bag review" of medications. The primary vehicle of each participant was instrumented with a small data collection device that records detailed driving data whenever the vehicle is operating and detects when a participant is driving. Annual follow-up is being conducted for up to three years with a telephone questionnaire at 12 and 36 months and in-person assessment at 24 months. Medical records are reviewed annually to collect information on clinical diagnoses and healthcare utilization. Driving records, including crashes and violations, are collected annually from state motor vehicle departments. Pilot testing was conducted on 56 volunteers during March-May 2015. Recruitment and enrollment were completed between July 2015 and March 2017. CONCLUSIONS: Results of the LongROAD project will generate much-needed evidence for formulating public policy and developing intervention programs to maintain safe mobility while ensuring well-being for older adults.

RESUMEN

OBJECTIVE: Injury-related morbidity and mortality is an important emergency medicine and public health challenge in the United States. Here we describe the epidemiology of traumatic injury presenting to U.S. emergency departments (EDs), define changes in types and causes of injury among the elderly and the young, characterize the role of trauma centers and teaching hospitals in providing emergency trauma care, and estimate the overall economic burden of treating such injuries. METHODS: We conducted a secondary retrospective, repeated cross-sectional study of the Nationwide Emergency Department Data Sample (NEDS), the largest all-payer ED survey database in the United States. Main outcomes and measures were survey-adjusted counts, proportions, means, and rates with associated standard errors (SEs) and 95% confidence intervals. We plotted annual age-stratified ED discharge rates for traumatic injury and present tables of proportions of common injuries and external causes. We modeled the association of Level I or II trauma center care with injury fatality using a multivariable survey-adjusted logistic regression analysis that controlled for age, sex, injury severity, comorbid diagnoses, and teaching hospital status. RESULTS: There were 181,194,431 (SE = 4,234) traumatic injury discharges from U.S. EDs between 2006 and 2012. There was a mean year-to-year decrease of 143 (95% CI = -184.3 to -68.5) visits per 100,000 U.S. population during the study period. The all-age, all-cause case-fatality rate for traumatic injuries across U.S. EDs during the study period was 0.17% (SE = 0.001%). The case-fatality rate for the most severely injured averaged 4.8% (SE = 0.001%), and severely injured patients were nearly four times as likely to be seen in Level I or II trauma centers (relative risk = 3.9 [95% CI = 3.7 to 4.1]). The unadjusted risk ratio, based on group counts, for the association of Level I or II trauma centers with mortality was risk ratio = 4.9 (95% CI = 4.5 to 5.3); however, after sex, age, injury severity, and comorbidities were accounted for, Level I or II trauma centers were not associated with an increased risk of fatality (odds ratio = 0.96 [95% CI = 0.79 to 1.18]). There were notable changes at the extremes of age in types and causes of ED discharges for traumatic injury between 2009 and 2012. Age-stratified rates of diagnoses of traumatic brain injury increased 29.5% (SE = 2.6%) for adults older than 85 and increased 44.9% (SE = 1.3%) for children younger than 18. Firearm-related injuries increased 31.7% (SE = 0.2%) in children 5 years and younger. The total inflation-adjusted cost of ED injury care in the United States between 2006 and 2012 was $99.75 billion (SE = $0.03 billion). CONCLUSIONS: Emergency departments are a sensitive barometer of the continuing impact of traumatic injury as an important cause of morbidity and mortality in the United States. Level I or II trauma centers remain a bulwark against the tide of severe trauma in the United States, but the types and causes of traumatic injury in the United States are changing in consequential ways, particularly at the extremes of age, with traumatic brain injuries and firearm-related trauma presenting increased challenges.

Asunto(s)

Servicio de Urgencia en Hospital/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Heridas y Lesiones/epidemiología , Adolescente , Adulto , Distribución por Edad , Anciano , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/mortalidad , Niño , Preescolar , Comorbilidad , Estudios Transversales , Bases de Datos Factuales , Servicio de Urgencia en Hospital/economía , Femenino , Humanos , Lactante , Puntaje de Gravedad del Traumatismo , Masculino , Oportunidad Relativa , Estudios Retrospectivos , Centros Traumatológicos/economía , Estados Unidos/epidemiología , Heridas y Lesiones/clasificación , Heridas y Lesiones/economía , Heridas y Lesiones/etiología , Adulto Joven

Asunto(s)

Conducción de Automóvil , Cannabis , Accidentes de Tránsito , Vehículos a Motor , Psicotrópicos

RESUMEN

INTRODUCTION: Although some studies have reported an association between early exposure to anesthesia and surgery and long-term neurodevelopmental deficit, the clinical phenotype of children exposed to anesthesia is still unknown. METHODS: Data were obtained from the Western Australian Pregnancy Cohort Study (Raine) with neuropsychological tests at age 10 years measuring language, cognition, motor function, and behavior. Latent class analysis of the tests was used to divide the cohort into mutually exclusive subclasses of neurodevelopmental deficit. Multivariable polytomous logistic regression was used to evaluate the association between exposure to surgery and anesthesia and each latent class, adjusting for demographic and medical covariates. RESULTS: In our cohort of 1444 children, latent class analysis identified 4 subclasses: (1) Normal: few deficits (n=1135, 78.6%); (2) Language and Cognitive deficits: primarily language, cognitive, and motor deficits (n=96, 6.6%); (3) Behavioral deficits: primarily behavioral deficits, (n=151, 10.5%); and (4) Severe deficits: deficits in all neuropsychological domains (n=62, 4.3%). Language and cognitive deficit group children were more likely to have exposure before age 3 (adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.17-3.81), whereas a difference in exposure was not found between Behavioral or Severe deficit children (aOR, 1.00; 95% CI, 0.58-1.73, and aOR, 0.85; 95% CI, 0.34-2.15, respectively) and Normal children. CONCLUSIONS: Our results suggest that in evaluating children exposed to surgery and anesthesia at an early age, the phenotype of interest may be children with deficits primarily in language and cognition, and not children with broad neurodevelopmental delay or primarily behavioral deficits.

Asunto(s)

Anestesia/efectos adversos , Discapacidades del Desarrollo/inducido químicamente , Adulto , Niño , Trastornos de la Conducta Infantil/inducido químicamente , Trastornos de la Conducta Infantil/epidemiología , Trastornos de la Conducta Infantil/psicología , Preescolar , Trastornos del Conocimiento/inducido químicamente , Trastornos del Conocimiento/epidemiología , Trastornos del Conocimiento/psicología , Estudios de Cohortes , Comorbilidad , Discapacidades del Desarrollo/epidemiología , Discapacidades del Desarrollo/psicología , Femenino , Humanos , Lactante , Recién Nacido , Trastornos del Desarrollo del Lenguaje/inducido químicamente , Trastornos del Desarrollo del Lenguaje/epidemiología , Trastornos del Desarrollo del Lenguaje/psicología , Masculino , Pruebas Neuropsicológicas , Fenotipo , Embarazo , Procedimientos Quirúrgicos Operativos/efectos adversos , Australia Occidental/epidemiología

RESUMEN

Diabetic polyneuropathy (DPN) is a major cause of neuropathic pain and a frequent target condition in analgesic treatment trials. Differences in the clinical symptoms and signs associated with DPN suggest distinct pathophysiological mechanisms underlying nerve damage and dysfunction that are likely to have therapeutic relevance. The aim of this study was to develop a tool for the bedside assessment of painful neuropathies such as DPN that captures the diversity of phenotypes. Sixty-one patients with type 2 diabetes and painful neuropathy, 19 patients with painless DPN, 25 patients with type 2 diabetes but no clinical evidence of neuropathy, and 20 healthy control subjects completed a structured interview (47 items) and a standardized physical examination (39 items). After analyzing critical features of pain and painless symptoms and examining the outcome of physical tests of sensory function, we determined principal components of the phenotypic variance among patients. Increased sensitivity to mechanical or thermal stimuli and, to a lesser extent, the sensory quality of pain or paresthesia were the most discriminating elements of DPN phenotypes. Correlation patterns of symptoms and signs indicated the involvement of functionally distinct nerve fiber populations. We combined interview questions and physical tests identifying these differences in a shortened assessment protocol that we named Standardized Evaluation of Pain and Somatosensory Function (StEPS). The protocol StEPS generates a phenotypic profile of patients with neuropathy. Separate intensity ratings for spontaneous painful symptoms and pain evoked by standard stimuli support a detailed documentation of neuropathic pain and its response to analgesic treatment.

Asunto(s)

Diabetes Mellitus Tipo 2/complicaciones , Neuralgia/diagnóstico , Neuralgia/etiología , Dimensión del Dolor/normas , Índice de Severidad de la Enfermedad , Femenino , Humanos , Hiperalgesia/fisiopatología , Masculino , Persona de Mediana Edad , Umbral del Dolor/fisiología , Fenotipo , Análisis de Componente Principal , Curva ROC , Estadística como Asunto