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Loza-Avalos SE, DeAtkine E, Ochoa M, Treviño R, Diercks K, Edwards C, George J, Lunardi N, Paquette S, Bisgaard E, Kuhlenschmidt K, Cripps M, Park C. Burn and Trauma Burden and Screening for Interpersonal Violence During the COVID-19 Pandemic. J Surg Res 2024; 298:386-392. [PMID: 37957086 DOI: 10.1016/j.jss.2023.09.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION Nationwide shelter-in-place (SIP) orders during the pandemic have had long-lasting effects, including increased rates of domestic violence and interpersonal violence. Screening for violence varies by institution, which tool is used, and when. Given increases in burn and trauma admissions over the course of the pandemic, we sought to examine trends at our institution during this time period to better guide care and anticipate system-level effects. METHODS We performed a retrospective cohort study of pediatric burn and adult burn and trauma patients at our level 1 trauma/burn center between March-May 2019 and March-May 2020. Home safety screening was performed by nursing staff using a 1-part screening questionnaire. Patients presenting before March 15, 2020, were defined as "pre-SIP; " between March 16-May 19, 2020, were "during SIP; " and those after May 19, 2020, were designated as "post-SIP." Descriptive and chi-square statistics were used. Demographic, injury patterns, and screening information were collected. RESULTS Blunt trauma comprised 60% of injuries, followed by burns (30%) then penetrating injury (7%). Over the entire time period analyzed, 1822 patients had documented home safety screening; ∼2% of patients screened reported a safety concern pre-SIP, compared to 3% of patients during SIP. There were higher rates of burns and penetrating injury during SIP compared to other periods (P ≤ 0.0001). Home safety screening rates were 94%-95% pre- and during SIP, but dropped to 85% post-SIP (P < 0.0001). Home safety concerns were reported almost 2% of the time pre-SIP and 3% during SIP (P = 0.016). CONCLUSIONS We noted an increase in trauma and burns during and after SIP orders, consistent with the experiences of other institutions. Implementation of a nurse-driven screening process demonstrated high compliance with appropriate referrals. The burden of burn and traumatic injury remains significant, highlighting a need for continued psychosocial screening and the provision of psychosocial support resources in the acute trauma setting.
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Affiliation(s)
- Sandra E Loza-Avalos
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth DeAtkine
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Manuela Ochoa
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert Treviño
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kiersten Diercks
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Jessica George
- Department of Trauma, Parkland Memorial Hospital, Dallas, Texas
| | - Nicole Lunardi
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shannon Paquette
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Erika Bisgaard
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kali Kuhlenschmidt
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Cripps
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Caroline Park
- Division of Burns, Department of Surgery, Trauma and Acute Care Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
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2
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Levy L, Villavisanis DF, Sarosi AJ, Taub PJ. Pediatric Plastic Surgery in the COVID-19 Era. Ann Plast Surg 2024; 92:335-339. [PMID: 38394272 DOI: 10.1097/sap.0000000000003810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
ABSTRACT The COVID-19 pandemic has forced the healthcare system to adopt novel strategies to treat patients. Pediatric plastic surgeons are uniquely exposed to high rates of infections during examinations and surgeries via aerosol-generating procedures, in part because of the predilection of viral particles for the nasal cavities and pharynx. Telemedicine has emerged as a useful virtual medium for encouraging prolonged patient follow-up while maintaining physical distance. It has proven beneficial in mitigating infection risks while decreasing the financial burden on patients, their families, and healthcare teams. New trends driven by the pandemic added multiple elements to the patient-physician relationship and have left a lasting impact on the field of pediatric plastic surgery in clinical guidelines, surgical care, and patient outcomes. Lessons learned help inform pediatric plastic surgeons on how to reduce future viral infection risk and lead a more appropriately efficient surgical team depending on early triage.
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Affiliation(s)
- Lior Levy
- From the Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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3
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Arthur L, Schiro S, Tumin D, Nakayama D, Toschlog E, Greene E, Waddell M, Longshore S. Shelter in Place and an Alarming Increase in Penetrating Trauma in Children and Concerning Decrease in Child Abuse. Am Surg 2023; 89:5386-5390. [PMID: 36583224 DOI: 10.1177/00031348221148361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND On March 14, 2020, schools across North Carolina (NC) closed in response to Covid-19, forcing completion of the school year at home. Most pediatric trauma occurs at home with a higher prevalence when children are out of school. We queried the state trauma database to assess if the 2020 "shelter in place" was associated with an increase in pediatric trauma statewide. METHODS The NC trauma database was queried for injuries in children (age < 18 yrs) from 13 March-1 August 2020, and the corresponding months of 2018 and 2019. The number and type of injuries were compared. We also queried the NC death certificate and child welfare databases. Data were analyzed by standard statistical methods using chi-squared or Kruskal-Wallis test. RESULTS Total pediatric trauma cases were lower during 2020 (71.6 per 100,000) compared to 2018 (92.4 per 100,000) and 2019 (80 per 100,000) (P < .001); however, average injury severity score (ISS) was higher (P = .001). A significant increase in firearm injuries were seen in 2020 (P = .016), with an increase in mortality (P = .08) and ISS (P = .013). The rate of child abuse trauma decreased in 2020 (P = .005) as did the number of child abuse and neglect reports (P < .001). There were also significant decreases in trauma due to sports, burns, falls, and motor vehicle accidents. CONCLUSION While overall pediatric trauma decreased during the Covid-19 pandemic, there was an alarming increase in penetrating injuries in children. Child abuse trauma and reports decreased, which is concerning for lower identification of abuse.
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Affiliation(s)
- Lauren Arthur
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
- Vidant Center of Trauma & Surgical Critical Care, Vidant Medical Center, Greenville, NC, USA
| | - Sharon Schiro
- UNC Department of Surgery, North Carolina Office of Emergency Medical Services, Chapel Hill, NC, USA
- UNC Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Dmitry Tumin
- Department of Pediatrics, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Don Nakayama
- UNC Department of Surgery, University of North Carolina Hospitals at Chapel Hill, Chapel Hill, NC, USA
| | - Eric Toschlog
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
- Vidant Center of Trauma & Surgical Critical Care, Vidant Medical Center, Greenville, NC, USA
| | - Erika Greene
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
- Vidant Center of Trauma & Surgical Critical Care, Vidant Medical Center, Greenville, NC, USA
| | - Megan Waddell
- Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Shannon Longshore
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
- Vidant Center of Trauma & Surgical Critical Care, Vidant Medical Center, Greenville, NC, USA
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Kannikeswaran N, Ehrman RR, Vitale L, Oag K, Sundaralingam S, Spencer P, Donoghue L, Sethuraman U. Comparison of Trauma and Burn Evaluations in a Pediatric Emergency Department During Pre, Early and Late COVID-19 Pandemic. J Pediatr Surg 2023; 58:1803-1808. [PMID: 37032192 PMCID: PMC10019029 DOI: 10.1016/j.jpedsurg.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Pediatric trauma epidemiology altered during early COVID-19 pandemic period but the impact of the ongoing pandemic is unknown. OBJECTIVES To compare pediatric trauma epidemiology between the pre, early and late pandemic periods and to evaluate the association of race and ethnicity on injury severity during the pandemic. METHODS We performed a retrospective study of trauma consults for an injury/burn in children ≤16 years between January 1, 2019 and December 31, 2021. Study period was categorized into pre (January 1, 2019-February 28, 2020), early (March 1, 2020-December 31, 2020), and late (January 1, 2021-December 31, 2021) pandemic. Demographics, etiology, injury/burn severity, interventions and outcomes were noted. RESULTS A total of 4940 patients underwent trauma evaluation. Compared to pre-pandemic, trauma evaluations for injuries and burns increased during both the early (RR: 2.13, 95% CI: 1.6-2.82 and RR: 2.24, 95% CI: 1.39-3.63, respectively) and late pandemic periods (RR: 1.42, 95% CI: 1.09-1.86 and RR: 2.44, 95% CI: 1.55-3.83, respectively). Severe injuries, hospital admissions, operations and death were higher in the early pandemic but reverted to pre-pandemic levels during late pandemic. Non-Hispanic Blacks had an approximately 40% increase in mean ISS during both pandemic periods though they had lower odds of severe injury during both pandemic periods. CONCLUSIONS Trauma evaluations for injuries and burns increased during the pandemic periods. There was a significant association of race and ethnicity with injury severity which varied with pandemic periods. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Nirupama Kannikeswaran
- Central Michigan University, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, 540 E. Canfield Ave Detroit, MI 48201, USA
| | - Lisa Vitale
- Department of Surgery, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Katherine Oag
- Department of Surgery, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | | | - Priya Spencer
- Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Lydia Donoghue
- Department of Surgery, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Usha Sethuraman
- Central Michigan University, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, USA
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Christ A, Staud CJ, Wielscher M, Resch A, Teufelsbauer M, Radtke C. Impact of the COVID-19 pandemic on the epidemiology of severe burns : A single center study from a specialized burn center in Vienna. Wien Klin Wochenschr 2023; 135:244-250. [PMID: 36757443 PMCID: PMC9909650 DOI: 10.1007/s00508-022-02149-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/27/2022] [Indexed: 02/10/2023]
Abstract
INTRODUCTION Currently, very little detailed information on the epidemiological distribution and specificities of severely burned patients during the coronavirus disease 2019 (COVID-19) pandemic is available. This retrospective study aims to describe and compare this specific patient population based on 114 patients who were treated between March 2019 and March 2021 at the Center for Severe Burn Injuries at the Medical University of Vienna. METHODS To answer the research questions, a retrospective cohort study has been conducted over a period of 24 months, starting in March 2019 and ending in March 2021. To evaluate the epidemiological differences, the patients were divided into 2 observation periods of 12 months each. RESULTS In the period from 12 March 2020 to 11 March 2021, a total of 62 patients were admitted to the Center for Severe Burn Injuries. In comparison, only 52 patients were admitted in the same period of the previous year, which corresponds to an increase of 19.2%. In addition, it was noted that during the 2019-2020 observation period, 27% of patients were female and 73% male, whereas during the pandemic the gender distribution was 42% female and only 58% male. During the pre-pandemic observational period, 13 out of 52 patients admitted died (25%), whereas during the pandemic, 17 out of 62 patients succumbed to their injuries (27%). CONCLUSION Although the severity of the COVID-19 pandemic seems to be decreasing, especially due to the increasing availability of vaccines, there is a need for more data on the impact of the crisis on severely burned patients. In contrast to the current literature, we have seen a greater number of inpatient admissions to the Center for Severe Burn Injuries, as well as significant differences in gender distribution. Our data also suggest that the circumstances of the pandemic have no influence on the likelihood of survival for patients with severe burns.
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Affiliation(s)
- Alexandra Christ
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Clement J Staud
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Matthias Wielscher
- Department of Dermatology, Medical University of Vienna, Vienna, Austria
| | - Annika Resch
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Maryana Teufelsbauer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Christine Radtke
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Georgeades CM, Collings AT, Farazi M, Fallat ME, Minneci PC, Sato TT, Speck KE, Van Arendonk K, Deans KJ, Falcone RA, Foley DS, Fraser J, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St. Peter SD, Flynn-O’Brien KT. A Multi-institutional Study Evaluating Pediatric Burn Injuries During the COVID-19 Pandemic. J Burn Care Res 2022; 44:399-407. [PMID: 35985296 PMCID: PMC9452075 DOI: 10.1093/jbcr/irac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Indexed: 11/13/2022]
Abstract
During the COVID-19 pandemic, children were out of school due to Stay-at-Home Orders. The objective of this study was to investigate how the COVID-19 pandemic may have impacted the incidence of burn injuries in children. Eight Level I Pediatric Trauma Centers participated in a retrospective study evaluating children <18 years old with traumatic injuries defined by the National Trauma Data Bank. Patients with burn injuries were identified by ICD-10 codes. Historical controls from March to September 2019 ("Control" cohort) were compared to patients injured after the start of the COVID-19 pandemic from March to September 2020 ("COVID" cohort). A total of 12,549 pediatric trauma patients were included, of which 916 patients had burn injuries. Burn injuries increased after the start of the pandemic (COVID 522/6711 [7.8%] vs Control 394/5838 [6.7%], P = .03). There were no significant differences in age, race, insurance status, burn severity, injury severity score, intent or location of injury, and occurrence on a weekday or weekend between cohorts. There was an increase in flame burns (COVID 140/522 [26.8%] vs Control 75/394 [19.0%], P = .01) and a decrease in contact burns (COVID 118/522 [22.6%] vs Control 112/394 [28.4%], P = .05). More patients were transferred from an outside institution (COVID 315/522 patients [60.3%] vs Control 208/394 patients [52.8%], P = .02), and intensive care unit length of stay increased (COVID median 3.5 days [interquartile range 2.0-11.0] vs Control median 3.0 days [interquartile range 1.0-4.0], P = .05). Pediatric burn injuries increased after the start of the COVID-19 pandemic despite Stay-at-Home Orders intended to optimize health and increase public safety.
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Affiliation(s)
- Christina M Georgeades
- Corresponding Author: Christina Georgeades, MD Department of Surgery Medical College of Wisconsin 8701 W. Watertown Plank Road Milwaukee, WI 53226 Phone Number: 727-385-2203
| | - Amelia T Collings
- Department of Surgery, Indiana University, Indianapolis, IN, United States of America
| | - Manzur Farazi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States of America,Division of Pediatric Surgery, Children’s Wisconsin, Milwaukee, WI, United States of America
| | - Mary E Fallat
- Norton Children’s Hospital, Louisville, KY, United States of America,Hiram C. Polk, Jr Department of Surgery, University of Louisville, KY, United States of America
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States of America,Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Thomas T Sato
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States of America,Division of Pediatric Surgery, Children’s Wisconsin, Milwaukee, WI, United States of America
| | - K Elizabeth Speck
- Division of Pediatric Surgery, Mott Children’s Hospital, Ann Arbor, MI, United States of America
| | - Kyle Van Arendonk
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States of America,Division of Pediatric Surgery, Children’s Wisconsin, Milwaukee, WI, United States of America
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States of America,Department of Pediatric Surgery, Nationwide Children’s Hospital, Columbus, OH, United States of America
| | - Richard A Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH, United States of America,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - David S Foley
- Norton Children’s Hospital, Louisville, KY, United States of America,Hiram C. Polk, Jr Department of Surgery, University of Louisville, KY, United States of America
| | - Jason Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States of America
| | - Samir Gadepalli
- Division of Pediatric Surgery, Mott Children’s Hospital, Ann Arbor, MI, United States of America
| | - Martin S Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, MO, United States of America
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center; Cincinnati, OH, United States of America,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | - Matthew P Landman
- Department of Surgery, Indiana University, Indianapolis, IN, United States of America
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, WI, United States of America
| | - Troy A Markel
- Department of Surgery, Indiana University, Indianapolis, IN, United States of America
| | - Nathan Rubalcava
- Division of Pediatric Surgery, Mott Children’s Hospital, Ann Arbor, MI, United States of America
| | - Shawn D St. Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, United States of America
| | - Katherine T Flynn-O’Brien
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States of America,Division of Pediatric Surgery, Children’s Wisconsin, Milwaukee, WI, United States of America
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Neighbors CE, Wu AE, Wixted DG, Heidenfelder BL, Kingsbury CA, Register HM, Louzao R, Sloane R, Eckstrand J, Pieper CC, Faldowski RA, Denny TN, Woods CW, Newby LK. The Cabarrus County COVID-19 Prevalence and Immunity (C3PI) Study: design, methods, and baseline characteristics. Am J Transl Res 2022; 14:5693-5711. [PMID: 36105067 PMCID: PMC9452347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Coronavirus Disease 2019 (COVID-19) is a viral illness with public health importance. The Cabarrus County COVID-19 Prevalence and Immunity (C3PI) Study is a prospective, longitudinal cohort study designed to contribute valuable information on community prevalence of active COVID-19 infection and SARS-CoV-2 antibodies as the pandemic and responses to it have and continue to evolve. We present the rationale, study design, and baseline characteristics of the C3PI Study. METHODS We recruited 1,426 participants between June 2020 and August 2020 from the Measurement to Understand the Reclassification of Disease of Cabarrus/Kannapolis (MURDOCK) Study Community Registry and Biorepository, a previously established, community-based, longitudinal cohort. Participants completed a baseline survey and follow-up surveys every two weeks. A nested weighted, random sub-cohort (n=300) was recruited to measure the incidence and prevalence of active COVID-19 infection and SARS-CoV-2 IgG antibodies. RESULTS The sub-cohort was younger (56 vs 61 years), had more men (39.0% vs 30.9%), and a higher proportion of Hispanic (11.0% vs 5.1%) and Black participants (17.0% vs 8.2%) compared with the overall cohort. They had similar anthropometrics and medical histories, but a greater proportion of the sub-cohort had a higher educational degree (36.1% vs 31.3%) and reported a pre-pandemic annual household income of >$90,000 (57.1% vs 47.9%). CONCLUSION This study is part of a multisite consortium that will provide critical data on the epidemiology of COVID-19 and community perspectives about the pandemic, behaviors and mitigation strategies, and individual and community burden in North Carolina.
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Affiliation(s)
| | - Angie E Wu
- Duke Clinical Research Institute, Duke UniversityDurham, North Carolina, USA
| | - Douglas G Wixted
- Duke Clinical and Translational Science Institute, Duke UniversityDurham, North Carolina, USA
| | - Brooke L Heidenfelder
- Duke Clinical and Translational Science Institute, Duke UniversityDurham, North Carolina, USA
| | - Carla A Kingsbury
- Duke Clinical and Translational Science Institute, Duke UniversityDurham, North Carolina, USA
| | - Heidi M Register
- Duke Human Vaccine Institute, Duke UniversityDurham, North Carolina, USA
| | - Raul Louzao
- Duke Human Vaccine Institute, Duke UniversityDurham, North Carolina, USA
| | - Richard Sloane
- Center for The Study of Aging and Human Development, Duke University Medical CenterDurham, North Carolina, USA
| | - Julie Eckstrand
- Duke Clinical and Translational Science Institute, Duke UniversityDurham, North Carolina, USA
| | - Carl C Pieper
- Department of Biostatistics and Bioinformatics, Duke University Medical CenterDurham, North Carolina, USA
| | - Richard A Faldowski
- Center for The Study of Aging and Human Development, Duke University Medical CenterDurham, North Carolina, USA
| | - Thomas N Denny
- Duke Human Vaccine Institute, Duke UniversityDurham, North Carolina, USA
- Department of Medicine, Duke University Medical CenterDurham, North Carolina, USA
| | - Christopher W Woods
- Duke Global Health Institute, Duke UniversityDurham, North Carolina, USA
- Department of Medicine and Pathology, Duke University Medical CenterDurham, North Carolina, USA
| | - L Kristin Newby
- Duke Clinical Research Institute, Duke UniversityDurham, North Carolina, USA
- Duke Clinical and Translational Science Institute, Duke UniversityDurham, North Carolina, USA
- Division of Cardiology, Department of Medicine, Duke University Medical CenterDurham, North Carolina, USA
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8
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Altıner S, Tuncal S, Ünal Y, Çöl M, Büyükkasap Ç, Pekcici MR. The effect of COVID-19 pandemic on the number of patients in burns services. Int Wound J 2022; 19:1975-1979. [PMID: 35808900 PMCID: PMC9434328 DOI: 10.1111/iwj.13797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
This study was conducted to examine the effects of the coronavirus disease 2019 (COVID‐19) pandemic on the epidemiological characteristics and causes of burns in patients admitted to burns services. A total of 629 patients who applied to the burn center of our hospital on March 11 to June 11, 2019, and March 11 to June 11, 2020, were included in this single‐center, retrospective study. The demographic information of the patients, causes of burns, burn degrees, affected anatomical areas, admission times and burn surface areas were recorded retrospectively according to patient records. The findings of our study suggest that gender, age, causes of burns, affected anatomical areas and application times did not differ before and after the COVID‐19 pandemic. The number of cases has significantly decreased during the COVID‐19 pandemic compared with that of the previous year. As a result, burn trauma is an emergency; it is preventable and cannot be ignored. The COVID‐19 pandemic has had many effects on social, cultural and economic fields, as well as on the field of health.
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Affiliation(s)
- Saygın Altıner
- Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
| | - Salih Tuncal
- Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
| | - Yılmaz Ünal
- Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
| | - Mert Çöl
- Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
| | - Çağrı Büyükkasap
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Turkey
| | - M Recep Pekcici
- Department of General Surgery, Ankara Training and Research Hospital, Ankara, Turkey
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9
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Wieck MM, Silva T, Kohler JE. Changing Patterns of Pediatric Trauma During the COVID-19 Pandemic. Pediatr Ann 2022; 51:e286-e290. [PMID: 35858219 DOI: 10.3928/19382359-20220504-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The implementation of lockdown and social distancing policies at the beginning of the coronavirus disease 2019 (COVID-19) pandemic changed both the nature of pediatric traumatic injuries and how those injuries were managed by pediatric trauma centers. At the start of the pandemic, the number of injured children evaluated at trauma centers decreased. Trauma volumes have since rebounded, and a concerning increase in abuse-related injuries has been seen. Pediatric trauma systems responded to the pandemic with new approaches to protect health care providers, conserve critical resources, and assist adult trauma systems overburdened by patients with COVID-19. The widespread effect of COVID-19 continues to have significant repercussions on children's health, but the lessons learned and gaps exposed by the pandemic may be an opportunity to positively transform injury prevention and health care delivery. [Pediatr Ann. 2022;51(7):e286-e290.].
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10
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Proulx K, Lenzi-Weisbecker R, Hatch R, Hackett K, Omoeva C, Cavallera V, Daelmans B, Dua T. Nurturing care during COVID-19: a rapid review of early evidence. BMJ Open 2022; 12:e050417. [PMID: 35680273 PMCID: PMC9184993 DOI: 10.1136/bmjopen-2021-050417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/23/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic has brought significant changes to family life, society and essential health and other services. A rapid review of evidence was conducted to examine emerging evidence on the effects of the pandemic on three components of nurturing care, including responsive caregiving, early learning, and safety and security. DESIGN Two academic databases, organisational websites and reference lists were searched for original studies published between 1 January and 25 October 2020. A single reviewer completed the study selection and data extraction with verification by a second reviewer. INTERVENTIONS We included studies with a complete methodology and reporting on quantitative or qualitative evidence related to nurturing care during the pandemic. PRIMARY AND SECONDARY OUTCOME MEASURES Studies reporting on outcomes related to responsive caregiving, early learning, and safety and security were included. RESULTS The search yielded 4410 citations in total, and 112 studies from over 30 countries met our eligibility criteria. The early evidence base is weighted towards studies in high-income countries, studies related to caregiver mental health and those using quantitative survey designs. Studies reveal issues of concern related to increases in parent and caregiver stress and mental health difficulties during the pandemic, which was linked to harsher and less warm or responsive parenting in some studies. A relatively large number of studies examined child safety and security and indicate a reduction in maltreatment referrals. Lastly, studies suggest that fathers' engagement in caregiving increased during the early phase of the pandemic, children's outdoor play and physical activity decreased (while screen time increased), and emergency room visits for child injuries decreased. CONCLUSION The results highlight key evidence gaps (ie, breastfeeding support and opportunities for early learning) and suggest the need for increased support and evidence-based interventions to ensure young children and other caregivers are supported and protected during the pandemic.
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Affiliation(s)
- Kerrie Proulx
- Research and Evaluation, FHI 360, Durham, North Carolina, USA
- Alliance for Human Development, Samuel Lunenfeld Research Institute of Mount Sinai Hospital, Toronto, Ontario, Canada
| | | | - Rachel Hatch
- Research and Evaluation, FHI 360, Durham, North Carolina, USA
| | - Kristy Hackett
- Research and Evaluation, FHI 360, Durham, North Carolina, USA
- Epidemiology Division, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Carina Omoeva
- Research and Evaluation, FHI 360, Durham, North Carolina, USA
| | - Vanessa Cavallera
- Department of Mental Health and Substance Abuse Use, WHO, Geneva, Switzerland
| | - Bernadette Daelmans
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, WHO, Geneva, Switzerland
| | - Tarun Dua
- Department of Mental Health and Substance Abuse Use, WHO, Geneva, Switzerland
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11
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Hutchinson ML, Nash KB, Abend NS, Moharir M, Wells E, Messer RD, Palaganas J, Helbig I, Wietstock SO, Suslovic W, Gonzalez AK, Kaufman MC, Press CA, Piantino J. Multicenter Study of the Impact of COVID-19 Shelter-In-Place on Tertiary Hospital-based Care for Pediatric Neurologic Disease. Neurohospitalist 2022; 12:218-226. [PMID: 35414846 PMCID: PMC8814588 DOI: 10.1177/19418744211063075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objective To describe changes in hospital-based care for children with neurologic diagnoses during the initial 6 weeks following regional Coronavirus 2019 Shelter-in-Place orders. Methods This retrospective cross-sectional study of 7 US and Canadian pediatric tertiary care institutions included emergency and inpatient encounters with a neurologic primary discharge diagnosis code in the initial 6 weeks of Shelter-in-Place (COVID-SiP), compared to the same period during the prior 3 years (Pre-COVID). Patient demographics, encounter length, and neuroimaging and electroencephalography use were extracted from the medical record. Results 27,900 encounters over 4 years were included. Compared to Pre-COVID, there was a 54% reduction in encounters during Shelter-in-Place. COVID-SiP patients were younger (median 5 years vs 7 years). The incidence of encounters for migraine fell by 72%, and encounters for acute diagnoses of status epilepticus, infantile spasms, and traumatic brain injury dropped by 53%, 55%, and 56%, respectively. There was an increase in hospital length of stay, relative utilization of intensive care, and diagnostic testing (long-term electroencephalography, brain MRI, and head CT (all P<.01)). Conclusion During the initial 6 weeks of SiP, there was a significant decrease in neurologic hospital-based encounters. Those admitted required a high level of care. Hospital-based neurologic services are needed to care for acutely ill patients. Precise factors causing these shifts are unknown and raise concern for changes in care seeking of patients with serious neurologic conditions. Impacts of potentially delayed diagnosis or treatment require further investigation.
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Affiliation(s)
- Melissa L. Hutchinson
- Department of Pediatrics, Neurology
Division, The Ohio State University College of
Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Kendall B. Nash
- Departments of Neurology and
Pediatrics, Division of Child Neurology, University of California, San
Francisco, Benioff Children’s Hospital San Francisco, San Francisco,
CA, USA
| | - Nicholas S. Abend
- Departments of Neurology and
Pediatrics, Children’s Hospital of Philadelphia
and the University of Pennsylvania, Philadelphia PA, USA
| | - Mahendranath Moharir
- Division of Neurology, Department
of Pediatrics, The Hospital for Sick Children and
University of Toronto, Ontario, Canada
| | - Elizabeth Wells
- Center for Neuroscience and
Behavioral Medicine, Children’s National Hospital and the
George Washington University School of Medicine and Health
Sciences, Washington, DC, USA
| | - Ricka D. Messer
- Department of Pediatrics, Section
of Child Neurology, University of Colorado, Aurora, CO, USA
| | - Jamie Palaganas
- Department of Pediatrics, Division
of Child Neurology, Weill Cornell Medicine, New York Presbyterian
Hospital, New York, NY, USA
| | - Ingo Helbig
- Division of Neurology, Children’s Hospital of
Philadelphia, Philadelphia PA, USA
| | - Sharon O. Wietstock
- The Epilepsy NeuroGenetics
Initiative (ENGIN), Department of Biomedical and Health Informatics (DBHi),
Department of Neurology, University of
Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - William Suslovic
- Department of Neurology, Children’s National
Hospital, Washington, DC, USA
| | - Alexander K. Gonzalez
- The Epilepsy NeuroGenetics
Initiative (ENGIN). Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of
Philadelphia, Philadelphia PA, USA 1
| | - Michael C. Kaufman
- The Epilepsy NeuroGenetics
Initiative (ENGIN). Department of Biomedical and Health Informatics (DBHi), Children’s Hospital of
Philadelphia, Philadelphia PA, USA 1
| | - Craig A. Press
- Departments of Neurology and
Pediatrics, Children’s Hospital of Philadelphia
and the University of Pennsylvania, Philadelphia PA, USA
| | - Juan Piantino
- Department of Pediatrics, Section
of Child Neurology, Oregon Health & Science
University, Portland, OR, USA,Juan A. Piantino, Department of Pediatrics,
Section of Child Neurology, Oregon Health & Science University, MCR CDRC-P
707 SW Gaines St, Portland, OR 97239, USA.
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12
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Codner JA, De Ayala R, Gayed RM, Lamphier CK, Mittal R. The Impact of the COVID-19 Pandemic on Burn Admissions at a Major Metropolitan Burn Center. J Burn Care Res 2021; 42:1103-1109. [PMID: 34139753 PMCID: PMC8344912 DOI: 10.1093/jbcr/irab106] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The impact of the coronavirus disease 2019 (COVID-19) pandemic on admission patterns and outcomes at a burn center is still largely unknown. The aim of this study was to determine how the COVID-19 pandemic affected the epidemiology of burn admissions at a major metropolitan burn center. This retrospective cohort study examined how the COVID-19 pandemic affected burn volumes and time to presentation. All burn admissions were included from January 20 to August 31 for the years 2020, 2019, and 2018. The COVID-19 pandemic group included admissions from January 20, 2020 to August 31, 2020 and was compared to the nonpandemic group comprised of admissions from January 20 to August 31 in 2018 and 2019. Subgroup analysis was performed according to meaningful dates during the COVID-19 pandemic including the first U.S. COVID-19 case, shelter-in-place, and state reopening orders. Admission volumes were 403 patients in the COVID-19 pandemic group compared to a mean of 429 patients in the nonpandemic group, which correlated to a 5.8% decrease in volume during the pandemic. The pandemic group showed an increase in time to presentation of 1 day (P < .0001). Subgroup analysis demonstrated stable admission volumes and an increase in time to presentation of 1 day (P < .0001) at each time point. During shelter-in-place orders, there were higher rates of second/third-degree burns and operative burns (94.7 vs 56.3% and 45.6 vs 27%, P < .0001, P = .013). During the pandemic, there were stable admission volumes, delayed time to admission, and an increase in operative burns during shelter-in-place orders. This reinforces the need to maintain appropriate burn center staffing and resources during the COVID-19 pandemic.
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Affiliation(s)
- Jesse A Codner
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Rafael De Ayala
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Rita M Gayed
- Department of Pharmacology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | | | - Rohit Mittal
- Department of Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
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13
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Aggarwal N, Srivastava RK. Impact of COVID-19 on Patient Trends and Outcome: Results from a Tertiary Care Burn and Plastic Unit in Northern India. Indian J Plast Surg 2021; 54:172-176. [PMID: 34239240 PMCID: PMC8257301 DOI: 10.1055/s-0041-1729511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background
Burn and trauma injuries need emergency care and resuscitation, which required uninterrupted delivery of inpatient care services during the coronavirus disease 2019 (COVID-19) pandemic. Burn patients are physiologically immunocompromised, increasing the risk of COVID-19 infection in them. This study analyzes the impact of COVID-19 pandemic on patient trends in a burn and plastic unit and assesses the effect of COVID-19 infection in burns.
Methods
This single-center, retrospective observational case–control study was conducted in the Department of Burns, Plastic and Maxillofacial Surgery of a tertiary care hospital in New Delhi, India. Patient data was collected from April 1, 2019 to August 10, 2019 and from April 1, 2020 to August 10, 2020. All data of burns and trauma patients collected was analyzed and compared.
Results
There were total 350 admissions during COVID time period and 562 admissions during non-COVID time period. The admission rate, type of burn injury, and death rate did not vary significantly during the two time periods. Thermal burn was the most common type of burn injury. There were total 18 cases diagnosed to be COVID-19 positive during the pandemic. There were two deaths among COVID-19 positive burn cases.
Conclusion
This study finds no difference in patient patterns during COVID and non-COVID time period. Amongst burn patients, no increased risk of COVID-19 infection is seen with larger body surface area of burns. No increase in mortality is seen in burn patients infected with COVID-19.
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Affiliation(s)
- Nupur Aggarwal
- Department of Burns, Plastic and Maxillofacial Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Rakesh Kumar Srivastava
- Department of Burns, Plastic and Maxillofacial Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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14
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Kovler ML, Ziegfeld S, Ryan LM, Goldstein MA, Gardner R, Garcia AV, Nasr IW. Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic. CHILD ABUSE & NEGLECT 2021; 116:104756. [PMID: 33004213 PMCID: PMC7518108 DOI: 10.1016/j.chiabu.2020.104756] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 05/07/2023]
Abstract
BACKGROUND AND OBJECTIVES The Covid-19 pandemic has forced mass closures of childcare facilities and schools. While these measures are necessary to slow virus transmission, little is known regarding the secondary health consequences of social distancing. The purpose of this study is to assess the proportion of injuries secondary to physical child abuse (PCA) at a level I pediatric trauma center during the Covid-19 pandemic. METHODS A retrospective review of patients at our center was conducted to identify injuries caused by PCA in the month following the statewide closure of childcare facilities in Maryland. The proportion of PCA patients treated during the Covid-19 era were compared to the corresponding period in the preceding two years by Fisher's exact test. Demographics, injury profiles, and outcomes were described for each period. RESULTS Eight patients with PCA injuries were treated during the Covid-19 period (13 % of total trauma patients), compared to four in 2019 (4 %, p < 0.05) and three in 2018 (3 %, p < 0.05). The median age of patients in the Covid-19 period was 11.5 months (IQR 6.8-24.5). Most patients were black (75 %) with public health insurance (75 %). All injuries were caused by blunt trauma, resulting in scalp/face contusions (63 %), skull fractures (50 %), intracranial hemorrhage (38 %), and long bone fractures (25 %). CONCLUSIONS There was an increase in the proportion of traumatic injuries caused by physical child abuse at our center during the Covid-19 pandemic. Strategies to mitigate this secondary effect of social distancing should be thoughtfully implemented.
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Affiliation(s)
- Mark L Kovler
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Susan Ziegfeld
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leticia M Ryan
- Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mitchell A Goldstein
- Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Rebecca Gardner
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alejandro V Garcia
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Isam W Nasr
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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15
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Sanford EL, Zagory J, Blackwell JM, Szmuk P, Ryan M, Ambardekar A. Changes in pediatric trauma during COVID-19 stay-at-home epoch at a tertiary pediatric hospital. J Pediatr Surg 2021; 56:918-922. [PMID: 33516579 PMCID: PMC7817462 DOI: 10.1016/j.jpedsurg.2021.01.020] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/04/2021] [Accepted: 01/13/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Trauma is the leading cause of morbidity and mortality in the pediatric population. However, during the societal disruptions secondary to the coronavirus (COVID-19) stay-at-home regulations, there have been reported changes to the pattern and severity of pediatric trauma. We review our two-institution experience. METHODS Pediatric trauma emergency department (ED) encounters from the National Trauma Registry for a large, tertiary, metropolitan level 1 pediatric trauma center and pediatric burn admission at the regional burn center were extracted for children less than 19 years from March 15th thru May 15th during the years 2015-2020. The primary outcome was the difference in encounters during the COVID-19 (2020) epoch versus the pre-COVID-19 epoch (2015-2019). RESULTS There were 392 pediatric trauma encounters during the COVID-19 epoch as compared to 451, 475, 520, 460, 432 (mean 467.6) during the pre-COVID-19 epoch. Overall trauma admissions and ED trauma encounters were significantly lower (p < 0.001) during COVID-19. Burn injury admissions (p < 0.001) and penetrating trauma encounters (p = 0.002) increased during the COVID-19 epoch while blunt trauma encounters decreased (p < 0.001). Trauma occurred among more white (p = 0.01) and privately insured (p < 0.001) children, but no difference in suspected abuse, injury severity, mortality, age, or gender were detected. Sub-analysis showed significant decreases in motor vehicle crashes (p < 0.001), pedestrians struck by automobile (p < 0.001), all-terrain vehicle (ATV)/motorcross/bicycle/skateboard involved injuries (p = 0.02), falls (p < 0.001), and sports related injuries (p < 0.001). Fewer injuries occurring in the playground or home play equipment such as trampolines neared significance (p = 0.05). Interpersonal violence (assault, NAT, self-harm) was lower during the COVID-19 era (p = 0.04). For burn admissions, there was a significant increase in flame burns (p < 0.001). CONCLUSIONS Stay-at-home regulations alter societal patterns, leading to decreased overall and blunt traumas. However, the proportion of penetrating and burn injuries increased. Owing to increased stressors and time spent at home, healthcare professionals should keep a high suspicion for abuse and neglect.
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Affiliation(s)
- Ethan L Sanford
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas TX, United States; Children's Health, Division of Pediatric Anesthesiology, Dallas TX, United States; Children's Health, Division of Pediatric Critical Care, Dallas TX, United States; Outcome Research Consortium, Cleveland, OH, United States
| | - Jessica Zagory
- Department of Surgery, Division of Pediatric Surgery, Louisiana State University Health Sciences Center, New Orleans LA, United States; Department of Surgery, Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas TX, United States.
| | - James-Michael Blackwell
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas TX, United States
| | - Peter Szmuk
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas TX, United States; Children's Health, Division of Pediatric Anesthesiology, Dallas TX, United States; Outcome Research Consortium, Cleveland, OH, United States
| | - Mark Ryan
- Department of Surgery, Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas TX, United States
| | - Aditee Ambardekar
- Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas TX, United States; Children's Health, Division of Pediatric Anesthesiology, Dallas TX, United States
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