Previous trauma as a risk factor for recurrent trauma in rural northern Israel

Just my luck: How children's causal attributions contribute to injury prevention

PURPOSE

Traumatic injury in children, particularly adolescents, is both frequently and costly. In this study, we directly examined children's causal attributions for the recent traumas and asked them to propose prevention strategies of their own. We predict that children who attribute their injuries to their own actions, rather than an external force such as luck, will be more likely to develop strategies to avoid trauma in the future.

METHODS

All children aged 10 -18 years who presented to a Level 1 pediatric trauma center at an urban children's hospital over a ten-month period were identified and presented with a series of structured interview questions. They were asked to describe the cause of their injuries, whether they believed them to be avoidable, and what strategies, if any, they thought might have prevented their trauma.

RESULTS

46 children with an average age of 13.4 years were surveyed and the responses of 44 children were analyzed. Most injuries resulted from sports (24) or motor vehicle accidents (14). The remaining injuries were due to burns (4) and falls (2). Twelve (27%) children believed that their own behavior was to blame for their injuries. 32 children ascribed their injuries to circumstances outside of their control with the majority (30, 94%) viewing themselves as "unlucky." Children who accepted fault for injury and children who thought their accident was avoidable were more likely to be able to formulate a strategy for preventing future injury. Children who thought their accident was avoidable were also more likely to accept fault for it.

CONCLUSION

Children surveyed denied their own culpability and preferred to attribute their injuries to bad luck. Moreover, children who believed themselves to be simply unlucky were less able than others to propose strategies that might prevent further injury.

A multicenter, citywide report on recurrent violent injury

INTRODUCTION

The incidence of and risk factors for recurrent violent trauma are not well known. This information is needed to focus violence prevention efforts on at-risk cohorts. The purpose of this study was to determine the incidence of and risk factors for recurrence following violent injury in a large urban setting. We hypothesize that the overall incidence of recurrent violent injury is low but there are specific at-risk cohorts.

METHODS

A retrospective, citywide study of patients who sustained blunt assault or penetrating trauma from 2013 to 2019 was performed. Patients were tracked across all trauma centers using their name and date of birth. The primary outcome was incidence of recurrent violent injury, which was calculated by dividing the number of readmitted patients by the number who survived previous admissions due to penetrating trauma or blunt assault. Associations between readmission and injury severity score, abbreviated injury score, age, sex, hospital, mechanism of injury (MOI), and disposition were determined. Kaplan-Meier curves were plotted to determine the incidence of recurrent injury over time. A multivariable Cox proportional hazard model was used to examine the relationships between characteristics at first admission and time-to-readmission.

RESULTS

The recurrent injury rate was 836 patients (6.33%) out of 13,211 injured patients. Male, age 14-45 years old, discharge to jail or left against medical advice, and moderate/severe head injury were associated with re-injury. There was no association between recurrence and mechanism of injury or overall injury severity. Discharge to home was associated with a lower re-injury rate.

CONCLUSION

The low recurrent injury rate despite high injury prevalence suggests injury prevention efforts should target this demographic and their non-injured peers.

The impact of children's temperament on recurrent unintentional injuries: the role of paternal parenting styles as a mediator

Background

Unintentional injuries (UIs) pose a threat to the health of children all over the world and are a major global health problem. The recurrence of UIs are influenced by the host itself or environmental factors. Children's temperament and paternal parenting styles (PPS) are important potential factors for poor health outcomes, including recurrent unintentional injuries (recurrent UIs). Therefore, exploring the relationship among these variables may help reduce the likelihood of recurrent UIs in children.

Purpose

To elucidate the mediating effect of PPS in the relationship of children's temperament characteristics and recurrent UIs among children.

Methods

By multistage random cluster sampling method, a total of 2,850 pupils in grades four and five from 10 different schools were included. The survey included the characteristics of UIs in the past year, parenting styles, and children's temperament. Structural equation modeling (SEM) was used to examine the possible mediating effect of PPS between children's temperament and recurrent UIs.

Results

In this study, the incidence rate of recurrent UIs was 3.8%. In temperament, children with recurrent UIs had higher mean scores than the non-recurrent UIs group (t = -3.40, -3.52, -3.45, respectively; p < 0.001) in the activity, predictability, persistence. Meanwhile, the scores of negative PPS (punishing, over-interference, rejection, and overprotection) were higher in the recurrent UIs group than in the non-recurrent UIs group (t = -5.78, -5.05, -5.56, and -3.29; p < 0.001, < 0.001, < 0.001, < 0.001, respectively). Using a stepwise binary logistic regression model, grade (OR = 0.23, 95% CI [0.12-0.41], p < 0.001), activity (OR = 1.61, 95% CI [1.14-2.26], p = 0.007) and over-interference (OR = 2.28, 95% CI [1.37-3.80], p = 0.002) had a significant independent relationship with recurrent UIs. The SEM results indicated that children's temperament was significantly related to negative PPS (β = 0.26, p < 0.001) and recurrent UIs (β = 0.11, p = 0.029). The results of the bootstrap test confirmed the significance of the mediating effect of PPS (β = 0.06, p < 0.001) between children's temperament and recurrent UIs.

Conclusions

These results suggest that negative PPS plays an important role in mediating children's temperament and recurrent UIs. It is essential to consider PPS when creating tailored intervention programs to reduce children's recurrent UIs.

Injuries and frequent use of emergency department services: a systematic review

OBJECTIVE

To review all studies having examined the association between patients with physical injuries and frequent emergency department (ED) attendance or return visits.

DESIGN

Systematic review.

DATA SOURCE

Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched up to and including July 2019.

ELIGIBILITY CRITERIA

English and French language publications reporting on frequent use of ED services (frequent attendance and return visits), evaluating injured patients and using regression analysis.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers screened the search results, and assessed methodological quality using the Joanna Briggs Institute tool for prevalence studies. Results were collated and summarised using a narrative synthesis. A sensitivity analysis was performed to evaluate the repercussions of removing a study that did not meet the quality criteria.

RESULTS

Of the 2184 studies yielded by this search, 1957 remained after the removal of duplicates. Seventy-eight studies underwent full-text screening leaving nine that met the eligibility criteria and were included in this study: five retrospective cohort studies; two prospective cohort studies; one cross-sectional study; and one case-control study. Different types of injuries were represented, including fractures, trauma and physical injuries related to falls, domestic violence or accidents. Sample sizes ranged from 200 to 1 259 809. Six studies included a geriatric population while three addressed a younger population. Of the four studies evaluating the relationship between injuries and frequent ED use, three reported an association. Additionally, of the five studies in which the dependent variable was return ED visits, three articles identified a positive association with injuries.

CONCLUSIONS

Physical injuries appear to be associated with frequent use of ED services (frequent ED attendance as well as return ED visits). Further research into factors including relevant youth-related covariates such as substance abuse and different types of traumas should be undertaken to bridge the gap in understanding this association.

Keeping children safe: a model for predicting families at risk for recurrent childhood injuries

OBJECTIVE

Existing research on recurrent unintentional injury (UI) focuses on the individual child rather than family risks. This study developed a statistical model for identifying families at highest risk, for potential use in targeting public health interventions.

STUDY DESIGN

A retrospective birth cohort study of hospital and emergency room (ER) medical records of children born in Ziv hospital between 2005 and 2012, attending ER for UI between 2005 and 2015, was conducted.

METHODS

Using national IDs, we assigned children to mothers and created the family entity. Data were divided into two time periods. Negative binomial regression was used to examine predictive factors in the first period for recurrent child UI in the second period. Sensitivity analyses were conducted to examine the model's robustness.

RESULTS

Eight predictive factors for child injury (P < 0.05) were found: male gender, the number of UI visits, the number of illness visits, age 36-59 months, birth weight <1500 g, maternal ER visits, siblings' UI visits, and the number of younger siblings. Some predictive factors are documented in the literature; others are novel. Five were significant in all sensitivity analyses.

CONCLUSIONS

These factors can assist in predicting risk for a child's repeat UI and family's cumulative UI risk. The model may offer a valuable and novel approach to targeting interventions for families at highest risk.

Time after time: individuals with multiple fractures and injury recidivists in long eighteenth-century (c. 1666-1837) London

Investigating injury recidivism and individuals with multiple injuries is an area of growing interest in bioarchaeology. Differentiating between whether an individual sustained multiple injuries, represented by antemortem healed fractures, in one incident or in multiple incidents over the life course, is a major challenge. This research analyzed the skeletal remains of 721 adults (402 males, 319 females) from five post-medieval cemeteries from London, UK, known to include working class individuals for evidence of skeletal trauma - fractures, myositis ossificans, subluxations/dislocations, blunt force trauma, and sharp force trauma. A total of 164 individuals had more than two fractures; males were significantly more likely to have multiple (2+) fractures than females. An investigation of fracture recidivism incorporating a relative timeline of fracture events was possible because 14 individuals (12 males, two females) were identified as injury recidivists, meaning they had a combination of antemortem healed, antemortem healing, and/or perimortem fractures. This paper examines the distribution and relative timing of these fractures, incorporating contemporary clinical as well as social and historical context, noting that the majority of the fractures were likely to be caused by accidental mechanisms.

An accident at work? Traumatic lesions in the skeleton of a 4th millennium BCE "wagon driver" from Sharakhalsun, Russia

The study of ante-mortem trauma is a popular and important aspect of palaeopathological analysis. The majority of publications focus on a particular assemblage, skeletal element or type of fracture, with case studies of single individuals with multiple/unusual traumata being much rarer in the literature. This paper presents the case of an adult male from the Bronze Age site of Sharakhalsun, Russia, buried, uniquely, in a sitting position on a fully assembled wagon, who displayed evidence for multiple healed ante-mortem fractures of the cranium, axial and appendicular skeleton. The mechanisms and likely etiologies of the fractures are presented, with reference to modern and 19th century clinical literature, and possible interpretations suggested: that the individual was involved in a severe accident involving a wagon or draft animals, or both, a number of years before his death. The suggestion is also made that the unique burial position of the individual was a form of commemoration by the community of the survival and recovery of the individual from such a serious incident.

Trauma recidivism at an emergency department of a Swedish medical center

Background

To inform targeted prevention, we studied patterns of trauma recidivism and whether a first injury predicts the risk for a recurrent injury.

Methods

In a population-based study of 98,502 adult injury events 1999–2012, at the emergency department of Umeå University Hospital, Sweden, we compared non-recidivists with recidivists in terms of patients’ sex, age, type of injury and severity of the injury.

Results

Thirty-six percent of all patients suffered recurrent injuries, which were associated with a higher proportion of inpatient care and more hospital days. Young men and elderly women were at the highest risk for trauma recidivism. At 20 to 24 years, men had a 2.4 (CI 95 % 2.3–2.5) higher risk than women, a 90 years old woman had almost a 10-fold higher risk for another moderate/severe injury than a 20 years old one. A fracture were associated with a hazard ratio of 1.28 (CI 95 % 1.15–1.42) among men younger than 65 years and 1.31 (CI 95 % 1.12–1.54) for men older than 65 years for a subsequent moderate/severe injury. For women younger than 65 years a fracture was associated with a hazard ratio of 1.44 (CI 95 % 1.28–1.62) for a subsequent moderate/severe injury. A sprain carries a higher risk for a new moderate/severe injury for both men and women and in both age groups; the hazard ratio was 1.13 (CI 95 % 1.00–1.26) for men younger than 65 years, 1.42 (CI 95 % 1.01–1.99) for men older than 65 years, 1.19 (CI 95 % 1.05–1.35) for women younger than 65 years and 1.26 (CI 95 % 1.02–1.56) for women older than 65 years. A higher degree of injury severity was associated with a higher risk for a new moderate/severe injury.

Conclusion

Trauma recidivism is common and represents a large proportion of all injured. Age and sex are associated with the risk for new injury. Injury types and severity, also have implications for future injury.

Longitudinal assessment of injury recidivism among adults in the United States: findings from a population-based sample

Background

Repeated injuries, as known as injury recidivism, pose a significant burden on population health and healthcare settings. Therefore, identifying those at risk of recidivism can highlight targeted populations for primary prevention in order to improve health and reduce healthcare expenditures. There has been limited research on factors associated with recidivism in the U.S. Using a population-based sample, we aim to: 1) identify the prevalence and risk factors for injury recidivism among non-institutionalized adults; 2) investigate the trend in nationwide recidivism rates over time.

Methods

Using the Medical Expenditure Panel Survey (MEPS), 19,134 adults with at least one reported injury were followed for about 2 years. Reported injuries were those associated with healthcare utilization, disability days or any effects on self-reported health. The independent associations between risk factors for recidivism were evaluated incorporating a weighted logistic regression model.

Results

There were 4,136 recidivists representing over nine million individuals in the U.S. over a 2-year follow-up. About 44 % of recidivists sustained severe injuries requiring a hospitalization, a physician’s office visit or an emergency department visit. Compared with those who sustained a single injury, recidivists were more likely to be white, unmarried, reside in metropolitan areas, and report a higher prevalence of chronic conditions. Age, sex, race/ethnicity, marital status, urbanicity, region, diabetes, stroke, asthma and depression symptoms were significant predictors of recidivism. Significant interaction effects between age and gender suggested those in the 18–25 age group, the odds of being a recidivist were 1.45 higher among males than females adjusting for other covariates. While having positive screens for depression in both follow-up years was associated with 1.46 (95 % CI = 1.21–1.77) higher odds of recidivisms than the reference group adjusting for other variables.

Conclusions

We observed a higher recidivism rate among injured individuals in this study than previously reported. Our findings emphasize the pressing need for injury prevention to reduce the burden of repeated injuries. Preventative efforts may benefit from focusing on males between 18 and 25 years of age and those with comorbidities such as diabetes, stroke and depression.

Urban versus rural trauma recidivism: is there a difference?

PURPOSE

Understanding the characteristics of trauma recidivists may allow trauma centers to tailor prevention programs. We hypothesized that there would be an increased incidence of violent injuries and falls in the urban vs. rural recidivists, respectively.

METHODS

Trauma admissions from 2000 to 2011 were queried for incidences of recidivism. Age (<65 or ≥65 years), gender, Injury Severity Score (ISS, <9 or ≥9), mortality, and injury cause (fall, violence, or other) were analyzed with univariate analyses to test for differences between urban and rural patients. Significant variables were then included in a binary logistic model and further stratified based on environment.

RESULTS

There were a total of 19,600 trauma admissions from 2000 to 2011, representing 18,711 unique patients, with 1,690 admissions (8.6 %) attributed to 801 recidivists (4.3 %). The overall percentages of recidivist trauma admissions attributed to urban and rural patients were 8.6 and 6.9 %, respectively (p < 0.001). When adjusting for age ≥65 years as well as falls and violent injuries, patients from urban environments were at 1.12 times higher odds of being a recidivist than their rural counterparts [odds ratio (OR) 1.12; 95 % confidence interval (CI) 1.01-1.25; p = 0.039]. When stratified into rural and urban groups, falls and violent injuries were significant in both groups of recidivist admissions; however, age ≥65 years was only significant in rural recidivist admissions.

CONCLUSION

An urban trauma admission had 12 % higher odds of being attributed to a recidivist than its rural counterpart, when controlling for age and mechanism of injury (MOI). Age ≥65 years was a significant variable in rural but not urban recidivist admissions. Characterizing the recidivist may allow for targeted prevention and intervention programs to decrease repeat hospital visits.

Understanding Why Patients Return to the Emergency Department after Mild Traumatic Brain Injury within 72 Hours

INTRODUCTION

Although there are approximately 1.1 million case presentations of mild traumatic brain injury (mTBI) in the emergency department (ED) each year, little data is available to clinicians to identify patients who are at risk for poor outcomes, including 72-hour ED return after discharge. An understanding of patients at risk for ED return visits during the hyperacute phase following head injury would allow ED providers to develop clinical interventions that reduce its occurrence and improve outcomes.

METHODS

This institutional review board-approved consecutive cohort study collected injury and outcome variables on adults with the purpose of identifying positive predictors for 72-hour ED return visits in mTBI patients.

RESULTS

Of 2,787 mTBI patients, 145 (5%) returned unexpectedly to the ED within 72 hours of hospital discharge. Positive predictors for ED return visits included being male (p=0.0298), being black (p=0.0456), having a lower prehospital Glasgow Coma Score (p=0.0335), suffering the injury due to a motor vehicle collision (p=0.0065), or having a bleed on head computed tomography (CT) (p=0.0334). ED return visits were not significantly associated with age, fracture on head CT, or symptomology following head trauma. Patients with return visits most commonly reported post-concussion syndrome (43.1%), pain (18.7%), and recall for further clinical evaluation (14.6%) as the reason for return. Of the 124 patients who returned to the ED within 72 hours, one out of five were admitted to the hospital for further care, with five requiring intensive care unit stays and four undergoing neurosurgery.

CONCLUSION

Approximately 5% of adult patients who present to the ED for mTBI will return within 72 hours of discharge for further care. Clinicians should identify at-risk individuals during their initial visits and attempt to provide anticipatory guidance when possible.

A novel prospective approach to evaluate trauma recidivism: the concept of the past trauma history

BACKGROUND

The purpose of this study was to determine the incidence and burden of trauma recidivism at a regional Level 1 trauma center by incorporating the concept of the past trauma history (PTHx) into the general trauma history.

METHODS

All trauma patients who met prehospital trauma criteria and activated the trauma team during a 13-month period were asked about their PTHx, that is, their history of injury in the previous 5 years. A recidivist presented more than once for separate severe injuries. Recurrent recidivists presented multiple times during the study period.

RESULTS

Of the 4,971 trauma activations during the study period, 1,246 (25.2%) were identified as recidivists. Recidivists were 75% male, 62% white, 36% unemployed, 26% uninsured, and 90% unmarried. The recidivism rate among admitted patients was 23.4% compared with 29.3% in those discharged from the emergency department. The highest recidivism rates were noted in patients who reported alcohol or illegal drug use on the day of injury and in victims of interpersonal violence (IPV), defined as those who sustained gunshot wounds, stab wounds, or assaults, Those involved in IPV were more likely to have been involved in IPV at the previous trauma than those with other trauma mechanisms. Key risk factors for recidivism among all patients were male sex and single marital status. Seventy-three patients (1.5%) were recurrent recidivists, representing 157 unique encounters.

CONCLUSION

This is the highest trauma recidivism rate reported on a large population of all consecutive trauma activations at a regional Level 1 trauma center. These data illustrate the tremendous burden of recidivism in the modern era, more than previously recognized. Efforts specifically targeting those involved in IPV may reduce recidivism rates. Incorporating the concept of the PTHx into the general history of the trauma patient is feasible and provides valuable information to the provider.

LEVEL OF EVIDENCE

Prognostic study, level II.

The risk of reinjury in relation to time since first injury: a retrospective population-based study

BACKGROUND

Trauma victims have been found to be at increased risk for reinjury. Determining the risk factors for reinjury and the temporal pattern of reinjury risk can help with targeting of intervention strategies for preventing trauma recurrence.

METHODS

We performed a retrospective, population-based study in Washington State from 1986 to 2001. Individuals aged 15 to 64 years who were hospitalized for injury were followed for 5 years for hospitalization or death because of reinjury. Poisson regression was used to determine the rate ratio of reinjury, compared with the baseline rate of injury, as a function of time since first injury. Among those injured, proportional hazards regression was used to determine risk factors for reinjury.

RESULTS

The risk of subsequent injury hospitalization or death was elevated 2.59-fold (95% CI: 2.50, 2.68) during the period from 6 months to 5 years after the initial injury. Excluding from analysis the first 6 months after initial injury, the risk of reinjury was highest at 4.10 (95% CI: 3.83, 4.40) between 6 and 12 months after first injury, and then declined to approximately 2.0-fold increased risk above baseline by 30 months. Individuals with self-inflicted injuries were found to be at particularly high risk of reinjury [Hazard Ratio (HR) 2.60 (2.21, 3.05)]. Increasing age, male gender, and alcohol use were also associated with increased reinjury risk. Any injury to the face, spine, and extremities were associated with a decreased risk of reinjury.

CONCLUSIONS

Reinjury risk is highest soon after injury, but persists for at least 5 years after initial injury. Periodic interventions through 5 years after injury, particularly in certain high-risk groups, might have lasting effects on reinjury rates.

Health-related quality of life in urban surgical emergency department patients: comparison with a representative German population sample

BACKGROUND

Patients in emergency departments show a high prevalence of substance use. Quality of life is associated with substance use as well as socioeconomic status. Little is known about quality of life in substance-abusing young patients with minor trauma.

METHODS

An investigation in an Emergency Department in an inner city university hospital was conducted during 8 months. Overall, 1,596 patients completed the SF-36 and an established SES-questionnaire and were screened for substance use (harmful alcohol consumption (>or= 8 points in men and >or= 5 points in women on the Alcohol Use Disorders Identification Test (AUDIT), smoking and illicit drug use). Results were compared with a representative German population sample (German Federal Health Survey 1998).

RESULTS

Median age of participants was 32 years and 61.8% were male. Mean physical component summary score (PCS) of the Short Form-36 Health Survey (SF-36) was 53.4 +/- 8.3 points and significantly higher than the age and gender-stratified German Federal Health Survey-data. Mean mental component summary score (MCS) was 47.9 +/- 10.0 points and significantly lower than the age and gender-stratified German Federal Health Survey-data. In Emergency Department patients, prevalence of substance use was high and harmful alcohol consumption and illicit drug use were strongly associated with impaired mental health. Education and occupational status were strongly positively associated with physical health.

CONCLUSION

We conclude that there is a high prevalence of substance use in young patients with minor trauma and mental quality of life is impaired. Screening and brief intervention strategies to reduce substance-use associated disorders should consider these findings.

Trauma recidivism in a large urban canadian population

BACKGROUND

Prevention of trauma might be achieved by risk factor modification. Identification of such risk factors can be pursued by various means. Trauma recidivists may possess and highlight risk factors. Accordingly, trauma recidivists were analyzed as a method to elucidate trauma risk factors.

METHODS

A retrospective analysis of 13,057 trauma patients in Toronto was conducted. Forty-two recidivists were identified, and their first admission was compared with a control group of 84 non-recidivists.

RESULTS

The rate of trauma recidivism was 0.38% overall. Trauma recidivists were more likely to be from the inner city, male, homeless, suffering from chronic medical conditions. In addition, psychiatric conditions, an alcoholism history or any alcohol at the time of injury, intentionally injured, or engaged in criminal activity were also significantly more common in recidivists (p <0.05).

CONCLUSION

Risk factors for major trauma can be identified by analyzing recidivists in a large urban Canadian population.

Children hospitalized for accidental injuries: Israeli experiences

Of the total 411 cases of accidents occurring in the State of Israel during 1999, the 314 which were hospitalized at the Edith Wolfson Medical Center, constituting 7.2% of the total pediatric hospitalizations in that regional hospital, were analyzed and summarized. Mean age of the children was 6.6+/-4.4, and ratio of boys to girls was 65:35. Accidents were classified by location of occurrence: home (52.3%); road (19.3%); sports (17.4%); and school (11.6%). Grades of severity were as follows: light (children were discharged without handicaps) (13.2%); moderate (children had undergone surgical intervention with prolonged or permanent disability) (74%); severe (children were treated in intensive care units and had permanent irreversible handicaps) (12.9%). Loss of conscientiousness occurred in 13.3% of cases. Affected body parts included: limbs (52.7%); head and face (32.7%); spine (7%); and multisystem injury (14.6%). Mean duration of hospitalization was 3.1 (+/-2.6 days). Accidental injuries most often occurred in the afternoon and in the absence of parental supervision. These findings generate conclusions for preventive interventions.

The Role of Psychiatry in the Management of Acute Trauma Surgery Patients

BACKGROUND: Trauma is a leading cause of death and disability in the United States, with high prevalence and recidivism in individuals with psychiatric and substance abuse disorders. Half of these disorders go undiagnosed by the trauma team, resulting in adverse public health and economic consequences. METHOD: In a 16-week pilot study in the emergency department of an inner-city tertiary care hospital, a psychiatrist was integrated into the trauma surgery team by responding to all traumas and rounding with the staff 1 shift per week (March 1, 2000, through June 31, 2000). During this 16-week period, 375 patients passed through the trauma surgery service. Data on the frequency of psychiatric consultations were compared with those for a retrospectively selected control group consisting of all 360 patients passing through the trauma surgery service during the corresponding 16 weeks of the previous year (March 1, 1999, through June 31, 1999). To determine the prevalence of psychopathology, eligible patients seen during the psychiatrist's shift (N = 28) were assessed with a semistructured interview, and charts for eligible patients seen in the corresponding shift during the previous year (N = 18) were assessed according to the same criteria. Before the study, a 10-item, self-report questionnaire was completed by 16 (73%) of the 22 emergency medicine physicians who serve as front-line staff members. The survey assessed physicians' attitudes toward psychiatric consultation for psychopathology and addictions in trauma patients. RESULTS: Based on DSM-IV screening criteria, the prevalence of preexisting psychopathology was 68% (19/28), but before the psychiatrist's involvement, only 12% (2/16) of physicians surveyed had considered consulting psychiatry, even for patients with gross psychopathology. Before the psychiatrist's integration into the 16-week study period, 75% (9/12) of trauma patients were discharged without psychiatric consultation despite the fact that more than half had documented substance abuse. After the psychiatrist joined the team, staff awareness of psychopathology sharpened. The number of patients treated for a psychiatric disorder that was often the proximal cause of the traumatic event nearly doubled, even on shifts not covered in the study. CONCLUSIONS: The ability to identify and treat coexisting psychopathology requires trauma surgeons to routinely incorporate a psychiatrist into their evaluation and treatment algorithm. Such a change in physician awareness and motivation hinges on a psychiatrist's visible presence (even if brief) and regular, active participation in the emergency department.

Repeat EMS transports among elderly emergency department patients

OBJECTIVES

Previous studies of repeat care of the elderly have focused on trauma cases only. The purposes of this study were to identify repeat transports of elderly patients to the authors' emergency department (ED) by emergency medical services (EMS), to identify demographics, and to compare chief complaints.

METHODS

A population-based, retrospective cohort study was conducted. Data for this study were obtained from computerized registration files in an urban, university-affiliated ED with an annual census of approximately 60,000 visits. Patients were included if they were 65 years of age or older and they were transported by EMS in 1997. The repeater group included patients who had one or more EMS transports within the following 12 months. The comparison group was composed of all patients with no further EMS transport within the 12 months after the index visit. Demographics extracted from the database were gender, chief complaint, total number of visits, and time since previous visits. Repeats were characterized by frequency (number of visits in 12 months after the index visit), type (visit for same vs different complaint), and rate (time to the first return visit). Repeaters were defined as more than one visit within a 12-month period. Repeaters were subdivided as follows: "immediate" (within 72 hours), "short-term" (within 2 months), and "long-term" (within 12 months). Chi-square and 95% confidence intervals (95% CIs) were used. A p-value < 0.05 was considered statistically significant.

RESULTS

There were 365 (23%) repeaters and 1,212 (77%) nonrepeaters. Repeaters accounted for 811 (40%) of the total of 2,023 elderly patients transported by EMS. Fifty-seven percent of all elderly patients transported by EMS were female, with no significant difference between the repeaters and nonrepeaters. There were significantly fewer transports for a chief complaint of trauma among the repeaters than among the nonrepeaters (14% vs 26%, diff = 12, 95% CI = 9-15%). Among the 365 repeaters, 186 (51%) had two transports, 92 (15%) had three transports, 36 (10%) had four transports, and 51 (14%) had five or more transports. Of the return transports by repeaters, 40 (12%) were "immediate," 191 (52%) were "short-term," and 134 (36%) were "long-term."

CONCLUSION

Repeaters accounted for 18% of elderly ED patients transported by EMS and 40% of elderly transports to the authors' ED. There were significantly fewer trauma transports in the repeater group. One-half of the repeaters returned only once in a 12-month period and a third of these occurred more than three months apart. It is important to understand the characteristics of elderly EMS repeaters in order to use this opportunity for intervention.

Increased lifetime prevalence of dental trauma is associated with previous non-dental injuries, mental distress and high alcohol consumption

The purpose of the study was to assess the lifetime prevalence of dental injuries and risk factors involved in a general population-based birth cohort. The study population consisted of 5737 subjects who had participated in a health survey at the age of 31 years. Altogether 52% of the participants were women. This partly computer-based health survey included two questionnaires on previous dental and non-dental injuries, general health, occupational status and lifestyle. The current study was based on these questionnaires. The lifetime prevalence of dental fractures was 43% and the lifetime prevalence of dental luxations and exarticulations 14%. Men more commonly had dental injuries than women. Particularly mental distress and a history of previous injuries were shown to increase the risk for dental injuries. Furthermore, overweight and high alcohol consumption were positively associated with a high lifetime prevalence of tooth trauma. Regular physical activity decreased trauma occurrence. Socioeconomic status further affected the lifetime prevalence of dental injuries. The conclusion of the study was that personal, social and physical factors played a role in the occurrence of dental trauma.

High-risk periods for childhood injury among siblings

OBJECTIVE

To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling.

DESIGN

Retrospective cohort.

SETTING

King County, Washington. Participants. A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years).

OUTCOME MEASURES

The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use.

RESULTS

. There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56-1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk:.57; 95% confidence interval:.07-2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 21/2 months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children.

CONCLUSIONS

Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.

Trauma recurrence in the pediatric emergency population

BACKGROUND

A link between ambulatory trauma and trauma recurrence may be hypothesized: (a) children who present for trauma may be those with characteristics that place them at particular risk; (b) children who frequently present for trauma may be those who present because of parental anxiety; and (c) children may learn from traumatic episodes and therefore decrease their trauma risk.

METHODS

A retrospective chart review of billing data was conducted to determine the value of the emergency department trauma visit count as a predictor of future trauma visits and to validate one of the models described above.

RESULTS

Records for 16,994 patients were obtained for the period January 1 through December 31, 1997, and these patients were followed as a cohort through the first 6 months of 1998. There were 9,236 males and 7,757 females. Of these, 5,413 patients had a trauma visit count in 1997 (TC97) of at least 1; 120 patients had a TC97 of 3 or more. The relationship between TC97 and trauma visit count in 1998 was linear, present in both males and females and across all age categories, with odds ratios for the group with TC97 > or =3 ranging from 3.8 to 6.4. Conversely, the risk of presentation with respiratory tract infection during the study period in 1998 was not increased with higher TC97 values.

CONCLUSION

Our data support the theory that children who present with trauma tend to be those with extrinsic or intrinsic factors that increase trauma risk. We have demonstrated a direct relationship between emergency department visit counts for trauma with future trauma occurrence risk. This relationship is present at all ages and in both males and females. The emergency trauma visit count is an easily obtained measure that has merit as an index to identify higher-risk children for possible intervention strategies. Further work is needed.