Violent trauma as an indirect impact of the COVID-19 pandemic: A systematic review of hospital reported trauma

Trends in Traumatic Brain Injuries During the COVID-19 Pandemic: A Single-Center Review of Patient Charts From Pakistan

Introduction A traumatic brain injury (TBI) is one of the leading causes of injury-related deaths, making it a public health concern of extreme importance. In a developing country such as Pakistan, TBIs are significantly underreported, with the treatment frequently being delayed and inadequate, especially in rural healthcare setups all across the country. This concern is further magnified by insufficient epidemiological data on TBIs available in Pakistan. The coronavirus disease 2019 (COVID-19) pandemic brought consequential changes to the healthcare system with the priority shifting toward COVID-19 patients, resulting in considerable changes to the workflow and management of TBIs. The primary objective of this study is to offer valuable insights into the epidemiology of TBIs in Pakistan and its relationship with the impact of the COVID-19 pandemic.  Methods A retrospective study was conducted at a tertiary care center in a metropolitan city in Pakistan. Patient charts were reviewed from January to August 2020, and data was extracted including demographics, clinical presentation, management, and outcomes for cases of TBI. Results The total number of patients is 2126, male 78% and female 21.4%. The mean age of the patients was 28.85. The state of admissions at the hospital is at 99.7% for EME admissions and 0.282% for OPD admissions. Participants presented with loss of consciousness (70.7%), nosebleeds, (53.2%), vomiting (69.0%), and seizures (11.5%). The majority (51.1%) were related to road traffic accidents, followed by falls (20.7%), and assaults (4%). While 1202 (58.5%) of these were managed conservatively, others underwent surgical treatment in the form of craniotomy (28.0%), Burr holes (3.20%), and fracture elevation and repair (10.5%). A decrease in the number of reported TBI cases was observed with lockdown implementation in Pakistan. Conclusion The transportation sector in Pakistan was severely affected by the COVID-19 pandemic, leading to a decline in road traffic injuries and TBIs. Stringent mobility constraints and changes in societal and cultural norms have contributed to this reduction.

A cross-sectional study of the impact of the COVID-19 lockdown on domestic violence-related oral and maxillofacial injuries

BACKGROUND

During the COVID-19 lockdown, more domestic violence-related traumas were reported. In this study, we investigated and compared the incidence of domestic violence-related injuries-in particular oral and maxillofacial injuries-in Ulaanbaatar, Mongolia, before and during the COVID-19 lockdown.

MATERIALS AND METHODS

We conducted a cross-sectional study based on 3974 domestic violence cases registered at the Public Health Department, National Traumatology and Orthopedics Research Center of Mongolia between 2018 and 2022. Descriptive and binary logistic regression analyses were conducted. The victims were categorized according to their age (child, adult, and elderly).

RESULTS

The mean age of the victims was children 9.7 ± 5.4 years, adults 34.8 ± 8.3 years, and elderly 64.3 ± 8.7 years. Binary logistic regression analysis (no/yes) showed that oral and maxillofacial injuries during the lockdown increased 1.3 times (OR = 1.3; CI 95% = 1.0-1.6; p = .003) in adults and 2.5 times in children (OR = 2.5; CI 95% = 1.7-3.9; p = .001). Additionally, injuries to upper limbs increased 4.6 times (OR = 4.6; CI 95% = 3.5-6.1; p = .001) in adults and 5.2 times in elderly patients (OR = 5.2; CI 95% = 1.8-16.2; p = .01). Additionally, thorax injury in children increased 3.1 times (OR = 3.1; CI 95% = 1.7-5.7; p = .001).

CONCLUSIONS

During the lockdown, injury to oral and maxillofacial regions increased in adult and child victims of domestic violence.

Stepped collaborative care versus American College of Surgeons Committee on Trauma required screening and referral for posttraumatic stress disorder: Clinical trial protocol

BACKGROUND

Each year in the US, approximately 1.5-2.5 million individuals are so severely injured that they require inpatient hospital admissions. The American College of Surgeons Committee on Trauma (College) now requires that trauma centers have in place protocols to identify and refer hospitalized patients at risk injury psychological sequelae. Literature review revealed no investigations that have identified optimal screening, intervention, and referral procedures in the wake of the College requirement.

METHODS

The single-site pragmatic trial investigation will individually randomize 424 patients (212 intervention and 212 control) to a brief stepped care intervention versus College required mental health screening and referral control conditions. Blinded follow-up interviews at 1-, 3-, 6-, and 12-months post-injury will assess the symptoms of PTSD and related comorbidity for all patients. The emergency department information exchange (EDIE) will be used to capture population-level automated emergency department and inpatient utilization data for the intent-to-treat sample. The investigation aims to test the primary hypotheses that intervention patients will demonstrate significant reductions in PTSD symptoms and emergency department/inpatient utilization when compared to control patients. The study incorporates a Rapid Assessment Procedure-Informed Clinical Ethnography (RAPICE) implementation process assessment.

CONCLUSIONS

The overarching goal of the investigation is to advance the sustainable delivery of high-quality trauma center mental health screening, intervention, and referral procedures for diverse injury survivors. An end-of-study policy summit will harness pragmatic trial data to inform the capacity for US trauma centers to implement high-quality acute care mental health screening, intervention and referral services for diverse injured patient populations.

TRIAL REGISTRATION

Clinicaltrials.govNCT05632770.

Increases in adolescent firearm injuries were associated with school closures during COVID-19

BACKGROUND

Mitigation measures, including school closures, were enacted to protect the public during the COVID-19 pandemic. However, the negative effects of mitigation measures are not fully known. Adolescents are uniquely vulnerable to policy changes since many depend on schools for physical, mental, and/or nutritional support.  This study explores the statistical relationships between school closures and adolescent firearm injuries (AFI) during the pandemic.

METHODS

Data were drawn from a collaborative registry of 4 trauma centers in Atlanta, GA (2 adult and 2 pediatric). Firearm injuries affecting adolescents aged 11-21 years from 1/1/2016 to 6/30/2021 were evaluated. Local economic and COVID data were obtained from the Bureau of Labor Statistics and the Georgia Department of Health. Linear models of AFI were created based on COVID cases, school closure, unemployment, and wage changes.

RESULTS

There were 1,330 AFI at Atlanta trauma centers during the study period, 1,130 of whom resided in the 10 metro counties. A significant spike in injuries was observed during Spring 2020. A season-adjusted time series of AFI was found to be non- stationary (p = 0.60). After adjustment for unemployment, seasonal variation, wage changes, county baseline injury rate, and county-level COVID incidence, each additional day of unplanned school closure in Atlanta was associated with 0.69 (95% CI 0.34- 1.04, p < 0.001) additional AFIs across the city.

CONCLUSION

AFI increased during the COVID pandemic. This rise in violence is statistically attributable in part to school closures after adjustment for COVID cases, unemployment, and seasonal variation. These findings reinforce the need to consider the direct implications on public health and adolescent safety when implementing public policy.

Changes in ambulance departures for assault calls during COVID-19 pandemic restrictions

Restrictions related to COVID-19 changed the daily behavior of people, including the expression of violence. Although an increased incidence of violent behavior, especially domestic violence, was expected during the pandemic, retrospective analyses have yielded mixed results. Records of ambulance departures to address injuries caused by assaults in the Pilsen region, Czech Republic, during the restrictive measures during the national state of emergency were compared to data from 3 previous years using general linear models. The number and severity of assaults were analyzed for the whole sample and separately for patients of either sex, for residential or nonresidential locations, and for domestic violence. Controlling for the seasonal effects, the number of assaults decreased by 39% during the pandemic restrictions compared to the 3 previous years. No difference was found between the effects of restrictions on assaults resulting in an injury of a male or female patient. The decrease was specifically pronounced in the sample of assaults in nonresidential locations, while no effect of restrictions was observed in assaults in residential locations and domestic assaults. Pandemic restrictions were associated with a decreased incidence of violent assaults that required ambulance services. Although the incidence decreased especially in those assaulted outside of their homes, we found no support for an increase in domestic violence or violence against women. Pandemic restrictions may have served as a protective rather than a risk factor for assaults severe enough to warrant a call for ambulance services.

National evaluation of the association between stay-at-home orders on mechanism of injury and trauma admission volume

BACKGROUND

The COVID-19 pandemic had numerous negative effects on the US healthcare system. Many states implemented stay-at-home (SAH) orders to slow COVID-19 virus transmission. We measured the association between SAH orders on the injury mechanism type and volume of trauma center admissions during the first wave of the COVID-19 pandemic.

METHODS

All trauma patients aged 16 years and older who were treated at the American College of Surgeons Trauma Quality Improvement Program participating centers from January 2018-September 2020. Weekly trauma patient volume, patient demographics, and injury characteristics were compared across the corresponding SAH time periods from each year. Patient volume was modeled using harmonic regression with a random hospital effect.

RESULTS

There were 166,773 patients admitted in 2020 after a SAH order and an average of 160,962 patients were treated over the corresponding periods in 2018-2019 in 474 centers. Patients presenting with a pre-existing condition of alcohol misuse increased (13,611 (8.3%) vs. 10,440 (6.6%), p <0.001). Assault injuries increased (19,056 (11.4%) vs. 15,605 (9.8%)) and firearm-related injuries (14,246 (8.5%) vs. 10,316 (6.4%)), p<0.001. Firearm-specific assault injuries increased (10,748 (75.5%) vs. 7,600 (74.0%)) as did firearm-specific unintentional injuries (1,318 (9.3%) vs. 830 (8.1%), p<0.001. In the month preceding the SAH orders, trauma center admissions decreased. Within a week of SAH implementation, hospital admissions increased (p<0.001) until a plateau occurred 10 weeks later above predicted levels. On regional sub-analysis, admission volume remained significantly elevated for the Midwest during weeks 11-25 after SAH order implementation, (p<0.001).

[Health impact of COVID pandemic. SESPAS Report 2022]

Objetivo

Presentar, a los 22 meses de que la Organización Mundial de la Salud declarara como pandemia la infección global por SARS-CoV-2 el 11 de marzo de 2020, el impacto hasta el momento de la pandemia en términos de salud física y mental.

Método

Se han revisado resultados procedentes de metaanálisis y revisiones sistemáticas, citándose para algún aspecto específico de interés artículos individuales. La información nacional procede de la Red Nacional de Vigilancia Epidemiológica (RENAVE).

Resultados

Hasta finales de octubre se habían producido más de 250 millones de infecciones y 5 millones de muertes. En España se han notificado 4,7 millones de infecciones, aunque la cifra real es superior a los 7 millones. Se ha reducido la esperanza de vida, con efectos especialmente dramáticos en grupos de población con comorbilidad y de edad avanzada. Se constata un empeoramiento de la salud mental general. Es previsible que algunos colectivos, como los/las profesionales sanitarios/as, en su mayoría mujeres, y trabajadores/as de primera línea, tengan un mayor riesgo de desarrollar patologías de salud mental en el futuro. La pandemia y las medidas de control han tenido otras consecuencias indeseables, como la disminución de la actividad asistencial, el aumento del sedentarismo y el aumento de la violencia de género.

Conclusiones

Son necesarios estudios longitudinales para determinar la magnitud de las consecuencias de la propia infección y de las medidas de control y las actuaciones necesarias.

The COVID-19 pandemic and associated increases in experiences of assault violence among black men with low socioeconomic status living in Louisiana

Background

The COVID-19 pandemic has had mental health, social, and economic implications among communities with high levels of social disadvantage; this may have impacted community violence rates. The objective of this study was to characterize overall trends in assault and social disadvantage of patients experiencing assault before and during the COVID-19 pandemic.

Methods

All trauma activations at a level one trauma center serving the entire southeast Louisiana region were included during March–August pre-COVID (2018–2019) and during COVID (2020). ICD-10 E-codes were used to identify trauma intent (assault vs. other). Assaults in this context are defined as physical injuries caused by an act of violence wherein the perpetrator was suspected or confirmed to have intended harm, injury, or death to the victim. Social disadvantage was assessed using the Area Deprivation Index (ADI). Change in the monthly rate of assault-trauma activations was assessed using negative binomial regression with adjustment for race, gender, and injury intent. The study was reviewed and approved by the Louisiana State University Health Sciences Institutional Review Board.

Results

A total of 4,233 trauma activations were included. The majority of activations occurred among men. Assaults increased from 27.5% of all activations pre-Covid to 35.6% during the pandemic. Penetrating trauma similarly increased from 29.5% to 35.7% of all activations. Negative binomial regression demonstrated that in addition to this increase in proportion of assaults relative to all activations, the monthly assault rate also increased by 20% during the pandemic. These increases were driven primarily by increased assaults among Black men. ADI rank did not change between study periods.

Conclusions

Health disparities in violence worsened during the pandemic: increased cases of assault occurred disproportionately among Black men, and assaults persisted in occurring primarily among low-ADI communities where burden had been high pre-pandemic. There is a critical need for resources and support to Black men, to mitigate violence and improve racial heath equity.