Trends in head injury mortality among 0-14 year olds in Scotland (1986-95)

Statistical analysis of the thickness and biomechanical properties of Japanese children's skulls

OBJECTIVE

The structure and strength of a child's skull are important in accurately determining what and how external forces were applied when examining head injuries. The aims of this study were to measure skull thickness and strength in children, evaluate sex differences, and investigate the correlation between skull thickness and strength and age.

MATERIALS AND METHODS

Skulls were obtained from 42 Japanese dead bodies under 20 years of age. During the autopsies, bone samples were taken from each skull. The length, width, and central thickness of the skulls were measured using calipers. Three-point bending tests were conducted, and bending load and displacement were recorded. Bending stress and bending strain were calculated, and Young's modulus, 0.2% proof stress, and maximum stress were obtained.

RESULTS

In cases under 1.5 years old, 14 out of 46 male samples and 20 out of 40 female samples did not fracture during the three-point bending test, though no significant sex differences were detected. No significant differences in age, sample thickness, Young's modulus, 0.2% proof stress, or maximum stress were detected between the sexes. The sample thickness, Young's modulus, 0.2% proof stress, and maximum stress increased significantly and logarithmically with age (R² = 0.761-0.899). Although age correlated with thickness, Young's modulus, and maximum stress more in females than in males, 0.2% proof stress correlated slightly better in males than in females.

CONCLUSION

The skulls of preschool children, in particular, are thin, have low strength, and are at high risk of fracturing even with relatively small external forces. Unlike adults, no significant sex differences in skull thickness or strength were observed in children.

Correlation Between Sports-Related Maxillofacial Injuries and Head Injuries: A Five-Year Retrospective Study

PURPOSE

As sports have become more diverse and demanding, the number of patients with a maxillofacial injury accompanied by a cranial injury or neurological symptoms has increased. This study examined the correlation between sports-related maxillofacial injuries and head injuries.

PATIENTS AND METHODS

Among the patients who visited the emergency department of Pusan National University Dental Hospital due to a maxillofacial injury from sporting activities between 2014 and 2018, those who additionally had head injuries were retrospectively examined. Sporting activities were classified according to the American Academy of Pediatrics classification, and severity of injuries was determined using the Facial Injury Severity Scale (FISS). Patients whose medical records showed neurological symptoms and who underwent brain computed tomography for concomitant head injury were selected. The association between each of these variables, including age and gender, was statistically analyzed.

RESULTS

A total of 95 patients were included in this study, most of whom were male teenagers, and cycling was the most common cause of injuries. The mean FISS score was 0.79. Brain computed tomography was conducted for 91 patients, and 28 patients reported neurological symptoms. Only 11 patients underwent advanced evaluation in the neurology or neurosurgery department. Most patients were diagnosed with contusion and concussion and were monitored without any treatment.

CONCLUSIONS

Higher FISS values did not reflect the severity of maxillofacial and head injury. In this study, there were some patients with cranial fracture and cerebral hemorrhage with mild neurosurgical symptoms of facial trauma. Although the incidence of head trauma is not high, the necessity of wearing protective equipment cannot be overemphasized because severe trauma is permanent. Neurological signs and symptoms of patients with maxillofacial trauma should not be overlooked and require a thorough evaluation.

Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review

This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.

Epidemiology of Traumatic Brain Injury in Europe: A Living Systematic Review

This systematic review provides a comprehensive, up-to-date summary of traumatic brain injury (TBI) epidemiology in Europe, describing incidence, mortality, age, and sex distribution, plus severity, mechanism of injury, and time trends. PubMed, CINAHL, EMBASE, and Web of Science were searched in January 2015 for observational, descriptive, English language studies reporting incidence, mortality, or case fatality of TBI in Europe. There were no limitations according to date, age, or TBI severity. Methodological quality was assessed using the Methodological Evaluation of Observational Research checklist. Data were presented narratively. Sixty-six studies were included in the review. Country-level data were provided in 22 studies, regional population or treatment center catchment area data were reported by 44 studies. Crude incidence rates varied widely. For all ages and TBI severities, crude incidence rates ranged from 47.3 per 100,000, to 694 per 100,000 population per year (country-level studies) and 83.3 per 100,000, to 849 per 100,000 population per year (regional-level studies). Crude mortality rates ranged from 9 to 28.10 per 100,000 population per year (country-level studies), and 3.3 to 24.4 per 100,000 population per year (regional-level studies.) The most common mechanisms of injury were traffic accidents and falls. Over time, the contribution of traffic accidents to total TBI events may be reducing. Case ascertainment and definitions of TBI are variable. Improved standardization would enable more accurate comparisons.

Incidence and mortality of moderate and severe traumatic brain injury in children: A ten year population-based cohort study in Norway

OBJECTIVE

In this study we wanted to estimate population-based rates of incidence and mortality of moderate and severe traumatic brain injury (TBI) in children in one specific region in Norway.

METHODS

In the region there are seven acute care hospitals (ACHs) in addition to a Level 1 trauma centre. Of 702 869 inhabitants (2014), 145 395 were children aged 0-16 years. Data were collected during ten years (2004-2014). All children aged 0-16 years with moderate (Glasgow Coma Scale [GCS] score 9-13) or severe (GCS score ≤ 8) TBI admitted to the Level 1 trauma centre were prospectively included. Children treated outside the Level 1 trauma centre were retrospectively included from the ACHs. Children who died from TBI prehospitally were included from the National Cause of Death Registry. Poisson regression was used to estimate incidence rate ratios (with a 95% confidence interval) comparing age, sex, and time periods.

RESULTS

A total of 71 children with moderate or severe TBI were identified. Crude incidence rates were 2·4 (95% CI 1·7-3·3) for moderate and 2·5 (95% CI 1·8-3·4) for severe TBI per 100 000 person-years (py). Mortality rate from TBI was 1·2 (95% CI 0·7-1·9) per 100 000 py, and 88% were prehospital deaths.

CONCLUSION

The incidence rates and mortality of moderate and severe TBI were low compared to international reports. Most likely explained by successful national prevention of TBI.

Morbidity and mortality from road traffic crashes in children in Metro West, City of Cape Town - 2014

The road traffic crash injury burden significantly impacts the lives of South African children. This study aimed to assess the fatal and non-fatal pattern of road traffic crash injury of children under 13 years old from Metro West, City of Cape Town, from 1 January until 31 December 2014. The data were stratified by age, sex and mechanism of road traffic crash. The overall mortality rate was 8.7 per 100 000 population and pedestrians contributed the most to this burden (72.5%). There were more male children involved in a road traffic crash (p = 0.0001). The greatest proportion of fatal and non-fatal road traffic crash injuries was observed in children aged 5-9 years. Fractures contributed to the greatest rate of years lived with disability (3.0 years of life lived with disability per 100 000). Our study found that the burden of road traffic crashes primarily affects male pedestrians aged 5-9 years old.

Traumatic Injury Leads to Inflammation and Altered Tryptophan Metabolism in the Juvenile Rabbit Brain

Neuroinflammation after traumatic brain injury (TBI) contributes to widespread cell death and tissue loss. Here, we evaluated sequential inflammatory response in the brain, as well as inflammation-induced changes in brain tryptophan metabolism over time, in a rabbit pediatric TBI model. On post-natal days 5-7 (P5-P7), New Zealand white rabbit littermates were randomized into three groups: naïve (no injury), sham (craniotomy alone), and TBI (controlled cortical impact). Animals were sacrificed at 6 h and 1, 3, 7, and 21 days post-injury for evaluating levels of pro- and anti-inflammatory cytokines, as well as the major components in the tryptophan-kynurenine pathway. We found that 1) pro- and anti-inflammatory cytokine levels in the brain injury area were differentially regulated in a time-dependent manner post-injury; 2) indoleamine 2,3 dioxygeenase 1 (IDO1) was upregulated around the injury area in TBI kits that persisted at 21 days post-injury; 3) mean length of serotonin-staining fibers was significantly reduced in the injured brain region in TBI kits for at least 21 days post-injury; and 4) kynurenine level significantly increased at 7 days post-injury. A significant decrease in serotonin/tryptophan ratio and melatonin/tryptophan ratio at 21 days post-injury was noted, suggesting that tryptophan metabolism is altered after TBI. A better understanding of the temporal evolution of immune responses and tryptophan metabolism during injury and repair after TBI is crucial for the development of novel therapeutic strategies targeting these pathways.

Keeping children safe at home: protocol for three matched case-control studies of modifiable risk factors for falls

BACKGROUND

Childhood falls result in considerable morbidity, mortality and health service use. Despite this, little evidence exists on protective factors or effective falls prevention interventions in young children.

OBJECTIVES

To estimate ORs for three types of medically attended fall injuries in young children in relation to safety equipment, safety behaviours and hazard reduction and explore differential effects by child and family factors and injury severity.

DESIGN

Three multicentre case-control studies in UK hospitals with validation of parental reported exposures using home observations. Cases are aged 0-4 years with a medically attended fall injury occurring at home, matched on age and sex with community controls. Children attending hospital for other types of injury will serve as unmatched hospital controls. Matched analyses will use conditional logistic regression to adjust for potential confounding variables. Unmatched analyses will use unconditional logistic regression, adjusted for age, sex, deprivation and distance from hospital in addition to other confounders. Each study requires 496 cases and 1984 controls to detect an OR of 0.7, with 80% power, 5% significance level, a correlation between cases and controls of 0.1 and a range of exposure prevalences.

MAIN OUTCOME MEASURES

Falls on stairs, on one level and from furniture.

DISCUSSION

As the largest in the field to date, these case control studies will adjust for potential confounders, validate measures of exposure and investigate modifiable risk factors for specific falls injury mechanisms. Findings should enhance the evidence base for falls prevention for young children.

Traumatic brain injury in infants and toddlers, 0-3 years old

OBJECT

Children 0-3 years old present a completely different neurotraumatic pathology. The growing and the development processes in this age group imply specific anatomical and pathophysiological features of the skull, subarachnoid space, CSF flow, and brain. Most common specific neurotraumatic entities in children 0-3 years old are cephalhematoma, subaponeurotic (subgaleal) hematoma, diastatic skull fracture, grow skull fracture, depressed ('ping-pong') skull fracture, and extradural hematoma.

METHODS

We present our 10 years experience in neuropediatric traumatic brain injuries, between 1999 and 2009, in the First Department of Neurosurgery and Pediatric Intensive Care Unit. Including criteria were children, 0-3 years old, presenting only traumatic brain injury. We excluded patients with politrauma, who require a different management.

RESULTS

We present the incidence of these specific head injuries, clinical and imagistic features, treatment, and outcome. We found 72 children with diastatic skull fracture, 61 cases with depressed ('ping-pong') skull fracture, 22 cases with grow skull fracture, 11 children harboring intrusive skull fracture, 58 cephalhematomas, 26 extradural hematomas, and 7 children with severe brain injury and major posttraumatic diffuse ischemia ('black-brain'). Usually, infants and toddlers present with seizures, pallor, and rapid loss of consciousness. First choice examination, in all children was cerebral CT-scan, and for follow-up, we performed cerebral MRI. We emphasize on the importance of seizure prevention in this age group. Children presenting with extensive diffuse ischemia ('black-brain') had a poor outcome, death occurring in all 7 cases.

CONCLUSION

Children 0-3 years old, present with a total distinctive pathology than adults. Children with head injury must be addressed to a pediatric department of neurosurgery and pediatric intensive care unit. Prophylaxis pays the most important role in improving the outcome.

Emergency department visits for nonfatal childhood injuries in Romania

BACKGROUND

Childhood injury rates are higher in low and middle-income countries than in high-income countries. Childhood injuries have not been widely studied in Romania, a middle-income country, because data sources are lacking.

OBJECTIVE

This study presents the first surveillance data of nonfatal childhood injuries from a large children's hospital in Cluj, a major city of Romania.

METHODS

This retrospective study included review of medical records of injured children of 0-18 years of age treated in a major city pediatric emergency department from 1999 to 2003.

RESULTS

In the 5-year study period, 1179 childhood injuries were treated in the emergency department, for an average of 236 patients per year. For the county of Cluj, this represents an annual average injury incidence of 197 per 100,000 children younger than 5 years, 140 per 100 000 children aged 5-14 years, and 135 per 100 000 for children aged 15-18 years. Unintentional injuries represented 77.8% of cases, 18% were self-harm and suicide attempts, and 4.3% were assaults.

CONCLUSION

These trends, among the first reported from Romania, can help identify priority prevention areas.

Neurotrauma pediatric scales

Cranial traumas have different particularities in infants, toddlers, preschool child, school child and teenagers. The assessment of these cases must be individualized according to age. It is completely different in children that in adults. Trauma scales, very useful in grading the severity and predicting outcome in traumatic brain injury, used in adults must be adapted in children. Children have age-related specificity and anatomic particularities, for each of this period of development. Neurotrauma scales, specific for infants and children, such as Pediatric Coma Scale, Children's Coma Score, Trauma Infant Neurological Score, Glasgow Coma Scale, Liege Scale are reviewed, as well as neurotrauma outcome scales, like Glasgow Outcome Scale, modified Rankin score, KOSCHI score and Barthel Index. The authors present these scales in an exhaustive manner for thoroughgoing pediatric neurotrauma standards.

Population-based study of paediatric head injury

AIM

There is a paucity of population-based studies regarding the spectrum of paediatric head injury from mild through serious to fatal paediatric head injury. The aims of the present study were to determine the incidence, demographics and outcome of significant head injury in a state-wide population of children aged 0-15 years. A secondary aim was to determine if any serious head injuries were being missed under the current management protocols of the state-wide trauma system.

METHODS

A retrospective review of significant head injury in all paediatric patients over a period of 2 years was undertaken. Data were collected from the Victorian State Trauma Outcome Registry and Monitoring database, the Victorian Emergency Minimum Dataset and from the Victorian Institute of Forensic Medicine.

RESULTS

The incidence of paediatric head injury in Victoria over the 2-year period was 765 per 100000 per year. The incidence of admitted head injuries was 75 per 100000 per year and the incidence of significant head injury was seven per 100000 or 151 children. Forty-one per cent of these injuries required surgical intervention. Mortality was 1.6 children per 100000. All patients who died presented with a Glasgow Coma Score (GCS) of 3 and had multiple other risk factors. There were no deaths in patients discharged from hospital. Demographic and clinical factors associated with higher mortality and morbidity was determined.

CONCLUSION

The incidence of significant paediatric head injury was low. Deaths occurred early and were always associated with significant early clinical features of severe head injury. This highlights the importance of strategies for the prevention of head injuries. There appeared to be no serious head injuries missed during the study period.

Why does Sweden have the lowest childhood injury mortality in the world? The roles of architecture and public pre-school services

Of interest is how some countries have achieved a profound reduction of child injury mortality. Still little is reported on the impact of a combination of urban planning, social welfare development and safety measures. We therefore present trends in childhood (0-14 years) injury mortality in Sweden 1966-2001 and discuss the factors behind any reductions observed. Annual total and cause-specific injury mortality rates were computed by age subgroups and gender. Trend analyses were performed with year as independent and mortality rate as dependent variable. A piecewise linear function was fitted to the annual mortality rates. Data were categorized into five 7-year intervals. In total, there were 5264 deaths due to injury in the study population during the period 1966-2001, of which 3368 (64%) were of boys and 1896 (36%) girls. The most frequent external cause of death was transport injury (48%), drowning (14%), homicide (5.8%), fire (5%), and fall (2.7%). About 66% (n=3474) of deaths occurred during the first half of the study period (1966-1981) with an average incidence rate of mortality 13.0 compared to 5.6 per 100,000 inhabitants during the second half of the period (1982-2001). For total injuries, there was a statistically significant decrease in mortality among all subgroups of children in both sexes. The slopes are greater among the younger children (0-4, 5-9 years) than the older ones (10-14 years). Several factors behind this strong decline of childhood injury mortality of interest to evaluate are (i) the implementation of the functionalist architectural style including transport separation, legislation and safety in cars; (ii) the expansion of public child day-care centers including more organized leisure activities; (iii) the establishment of long-term nationwide mandatory program for swim training among school children and (iv) local child-safety programs considering differences in exposure to risk between urban and rural areas.

Gender differences in adolescent injury characteristics: A population-based study of hospital A&E data

OBJECTIVES

To investigate patterns of adolescent home/leisure injury serious enough to require hospital attendance.

STUDY DESIGN

Population-based analysis of data collected by the Home and Leisure Accident Surveillance System (HASS/LASS).

METHODS

Study subjects were 0-17 year old residents of Airdrie and Coatbridge, Lanarkshire, Scotland, who attended Monklands Hospital Accident and Emergency (A&E) Department with a home/leisure injury during calendar years 1996-1999. Male to female relative risk ratios (M:F RRRs) for A&E attendance, fracture and hospital admission, stratified into sports and non-sports injuries, were calculated. Sports injuries were further analysed by specific sports and by whether the sports activity was organized or informal. Data were analysed in age groups corresponding to children's stage of schooling.

RESULTS

The M:F RRR for non-sports A&E attendances remained constant throughout childhood (1.35, 95% CI 1.30-1.39 in 0-17 year olds), whilst that for sports attendances increased sharply with age (2.50, 95% CI 0.89-7.02 in 0-4 year olds, increasing to 8.11, 95% CI 6.27-10.51 in 16-17 year olds). Of sports injury attendances, 50.3% were football-related. Football was overwhelmingly the main cause of boys' sports injury in both the organized and informal sports injury categories. When football injuries were excluded from the analysis, the widening teenage gender gap in injury risk disappeared. There was no significant gender difference in teenagers' rates of A&E attendance for injuries sustained during compulsory school physical education (PE), suggesting a dose-response relationship between sports participation and injury risk.

CONCLUSIONS

This study found significant gender inequalities in adolescent injury risk, which were largely attributable to boys' football injuries. Focusing prevention efforts on making football safer would, then, be a sensible strategy for reducing the overall burden of adolescent injury and for reducing sex inequalities in injury risk; however further research is needed to understand how the risks differ between organized and informal football. These findings are also interesting because of what they suggest about teenage girls' lack of participation in sport and habitual physical activity. This is clearly of public health concern because of the links between physical inactivity and a range of health problems.

Epidemiology of traumatic brain injury in children receiving intensive care in the UK

AIMS

To describe the epidemiology of children with traumatic brain injury (TBI) admitted to paediatric intensive care units (PICUs) in the UK.

METHODS

Prospective collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Eire between February 2001 and August 2003.

RESULTS

The UK prevalence rate for children (0-14 years) admitted to intensive care with TBI between February 2001 and August 2003 was 5.6 per 100,000 population per year (95% Poisson exact confidence intervals 5.17 to 6.05). Children admitted to PICUs with TBI were more deprived than the population as a whole (mean Townsend score for TBI admissions 1.19 v 0). The commonest mechanism of injury was a pedestrian accident (36%), most often occurring in children over 10. There was a significant summer peak in admissions in children under 10 years. Time of injury peaked in the late afternoon and early evening, a pattern that remained constant across the days of the week. Injuries involving motor vehicles have the highest mortality rates (23% of vehicle occupants, 12% of pedestrians) compared with cyclists (8%) and falls (3%). In two thirds of admissions (65%) TBI was an isolated injury.

CONCLUSIONS

TBI in children requiring intensive care is more common in those from poorer backgrounds who have been involved in accidents as pedestrians. The summer peak in injury occurrence for 0-10 year olds and late afternoon timing give clear targets for community based injury prevention.

Social deprivation and adult head injury: a national study

OBJECTIVES

To establish the association between measures of social deprivation, mechanisms of injury, patterns of care, and outcome following closed head injury.

METHODS

All Scottish adult A&E attendees with closed head injury (AIS Head > or =3) between July 1996 and December 2000 were studied.

RESULTS

Trauma was more common in individuals from more deprived areas. Within the trauma population head injury was relatively more common in patients from deprived areas; these individuals were more likely to sustain an isolated head injury as a result of an assault. Admission GCS was higher and normal physiology (as assessed by the RTS) was more common in individuals from more deprived areas. Recorded co-morbidity was similar between the two groups with the exception of a history of alcohol or substance abuse which was more common among patients from more deprived areas. Similar proportions of patients from more deprived and less deprived areas were transferred to the Regional Neurosurgical Centre. For patients who were transferred directly from A&E, time to neurosurgical theatre was similar for both groups. Length of hospital and ITU stay was less in patients from more deprived areas. After adjusting for known predictors of outcome using logistic regression analysis, there was no significant difference in mortality between patients from more deprived and less deprived areas.

CONCLUSIONS

Residing in a more deprived area is not associated with increased mortality from head injury among adults in Scotland. It is associated with different patterns of injury and a different process of care following presentation to hospital.

Risk factors for childhood major and minor head and other injuries in a nationally representative sample

OBJECTIVE

To assess the relationship between demographic, socioeconomic, family type and behavioural factors and childhood major and minor head and other injuries.

DESIGN, SUBJECTS AND SETTING

A cross-sectional study, on a large nationally representative sample of 5913 children aged 4-15 years (Health Survey for England, 1997).

MAIN OUTCOME MEASURES

Frequency of major and minor head and other injuries.

RESULTS

There were no significant associations between any of the socioeconomic factors and family type and major and minor injuries, except for major head injuries in children who lived in families receiving more than one social or financial benefit. Boys were 1.5 times more likely to suffer major head and other injuries than girls. Older children were significantly more likely to experience major and minor other injuries, but less likely to have major and minor head injuries, compared to younger children. High scores for conduct disorder and emotional symptoms were significant risk factors for other major injuries, while high scores for hyperactivity and conduct disorder were significantly related to major and minor head injuries. The risk factors assessed were often stronger for major than for minor injuries, and stronger for head than other injuries.

CONCLUSION

Boys and children who exhibit certain behavioural problems such as high levels of hyperactivity were significantly more likely to report major and minor injuries affecting the head region.