Minorities and foreign born are disproportionately affected by injuries due to violence: an analysis based on a National Trauma Registry 2008-2017

Outcomes of basic versus advanced prehospital life support in severe pediatric trauma

OBJECTIVE

The role of basic life support (BLS) vs. advanced life support (ALS) in pediatric trauma is controversial. Although ALS is widely accepted as the gold standard, previous studies have found no advantage of ALS over BLS care in adult trauma. The objective of this study was to evaluate whether ALS transport confers a survival advantage over BLS among severely injured children.

METHODS

A retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020 was conducted. All the severely injured children (age < 18 years and injury severity score [ISS] ≥16) were included. Patient survival by mode of transport was analyzed using logistic regression.

RESULTS

Of 3167 patients included in the study, 65.1% were transported by ALS and 34.9% by BLS. Significantly more patients transported by ALS had ISS ≥25 as well as abnormal vital signs at admission. The ALS and BLS cohorts were comparable in age, gender, mechanism of injury, and prehospital time. Children transported by ALS had higher in-hospital mortality (9.2% vs. 0.9%, p < 0.001). Following risk adjustment, patients transported by ALS teams were significantly more likely to die than patients transported by BLS (adjusted OR 2.27, 95% CI 1.05-5.41, p = 0.04). Patients with ISS ≥50 had comparable mortality rates in both groups (45.9% vs. 55.6%, p = 0.837) while patients with GCS <9 transported by ALS had higher mortality (25.9% vs. 11.5%, p = 0.019). Admission to a level II trauma center vs. a level I hospital was also associated with increased mortality (adjusted OR 2.78 (95% CI 1.75-4.55, p < 0.001).

CONCLUSIONS

Among severely injured children, prehospital ALS care was not associated with lower mortality rates relative to BLS care. Because of potential confounding by severity in this retrospective analysis, further studies are warranted to validate these results.

Gunshot casualties in Israel: A decade of violence

OBJECTIVE

The purpose of this study was to identify and characterize casualties hospitalized with assault (non-terror) related gunshot wounds (GSW) in Israel as a basis for determining the incidence, trends and at-risk population groups.

METHODS

This retrospective cohort study is based on data from the Israel National Trauma Registry. The data includes GSW casualties hospitalized between January 1, 2011 and December 31, 2020. Attempted suicide, unintentional injury, legal intervention, children (ages 0-9) and terror (Israeli-Arab conflict) related GSW were excluded. The remaining population was classified with an ICD-9-CM diagnosis code of 965.0-965.4.

RESULTS

The study population included 2,763 GSW admissions. A noticeable increase in GSW casualties was reported, from 206 hospitalization in 2011 to 456 in 2020. The proportion of Arab casualties increased from 73.3% of all GSW casualties in 2011 to 90.8% in 2020, far more than their proportion in the population (∼20%). The majority of the GSW casualties were males (95.8%) and between the ages of 20 and 29 (42.2%). Among severe/critical casualties, 19% of Arabs and 9.9% of Jews arrived by private car. Severe thoracic and abdominal injuries were the prominent injuries among fatal casualties (47.6 and 40.8, respectively). While the all-severity mortality rate was 5.6% (n = 147), 24.4% (n = 135) of severe/critical (ISS16+) casualties died, with no significant differences between Jews and Arabs. Forty percent of deaths occurred in the emergency department.

CONCLUSIONS

This study establishes that during the past decade in Israel, not only has there been a continuous increase in hospitalizations due to GSW, but also Arabs are at great risk of such related hospitalizations. Preventive strategies targeting at-risk groups are crucial for minimizing morbidity and mortality related to GSW in Israel.

Global burden and trends of firearm violence in 204 countries/territories from 1990 to 2019

Background

Gaps remained in the updated information of the firearm violence (FV) burden from a global landscape. Understanding the global burden of FV could contribute to decision-making.

Methods

Data on the FV burden, including physical violence by firearm (PVF), self-harm by firearm (SHF), and unintentional firearm injuries (UFI), were extracted from the Global Burden of Disease 2019. The temporal trends of age-standardized rate (ASR) were estimated using estimated annual percentage change (EAPC).

Results

In 2019, PVF, SHF, and UFI reported 710.64 × 10³, 335.25 × 10³, and 2,133.88 × 10³, respectively, incident cases worldwide. Their ASR (/100,000 people-years) were 9.31, 4.05, and 28.07. During 1990-2019, the overall incident ASRs of PVF presented an increasing trend (EAPC = 0.61, 95% confidence interval [CI]: 0.48 to 0.75). Notably, pronounced increasing trends were observed in Tropical Latin America, and North Africa and Middle East. However, incident trends of SHF and UFI declined globally, with the respective EAPCs being -0.68 (95% CI: -0.83 to -0.54) and -0.98 (95% CI: -1.19 to -0.77). In 2019, the ASR of death due to PVF, SHF, and UFI were 2.23, 0.65, and 0.26, and that of DALYs were 127.56, 28.10, and 17.64, respectively. Decreasing trends in the ASRs of FV were observed in most regions and countries worldwide over the past three decades, particularly that of PVF in Estonia.

Conclusion

The FV burden was heterogeneous across regions and countries, which was deeply subjected to socioeconomic factors. The findings highlighted that specific prevention strategies and interventions were required, particularly in the high prevalent settings.

Analysis of Trauma Injuries Among the Minority Population in Southern Israel-a District-Wide Study

BACKGROUND

We compared characteristics of traumatic injury between the Bedouin subpopulation, the largest minority group in southern Israel, and the other residents in this region.

METHODS

We assessed all the patients admitted with traumatic injuries during 2014-2018 to the only regional hospital in southern Israel.

RESULTS

The cohort comprised 10,734 patients, 4553 (42.5%) of Bedouin origin. Compared to the non-Bedouin subpopulation, in the Bedouin subpopulation, the proportion of injuries that occurred in males was higher, 74.3% vs. 53.7%, P < 0.001, and the proportion of burn injuries that occurred in children aged 0-14 years was higher, 84% vs. 49%. Among the Bedouin and non-Bedouin patients, the respective proportions with penetrating injuries were 10.7 and 5.4%; the respective proportions who arrived at the hospital by private vehicles were 62.0 and 33.1%. In multivariate analysis, the variables that were significant for increased odds for severe trauma were Bedouin origin, male gender, and arrival to the emergency room at night.

CONCLUSION

This study highlights the lack of access to basic infrastructure and healthcare among Bedouins in southern Israel. The high proportion of penetrating injuries in this subpopulation is apparently due to explosions of unexploded ordnance. The unavailability of electricity and waste removal in unrecognized villages contributes to burn injuries among Bedouin children. Poor accessibility of healthcare facilities and emergency medical transportation necessitates travel to hospitals by private car. The findings should direct trauma prevention programs to reduce burn and penetrating injuries and to increase accessibility to healthcare.

Undocumented migrants in French intensive care units in 2011-2018: retrospective nationwide study

PURPOSE

Whether undocumented migrants admitted to intensive care units (ICUs) have specific features is unknown. We aimed to determine the features and outcomes of undocumented migrants admitted to French ICUs.

METHODS

We retrospectively included all undocumented adult migrants admitted in 2011-2018 and compared them to the general ICU population. We also compared these two groups matched on age, sex, severity, comorbidities, reason for ICU admission and public/private hospital.

RESULTS

We identified 14,554 ICU stays, with an increase from 2 to 4‰ of all ICU admissions over time. Shock (16.7%), post-operative care (13.8%), and trauma (10.5%) were the main reasons for ICU admission. Compared to general ICU patients, migrants were younger and had greater disease severity. After adjustment on age and sex, the following were more common in migrants: shock (OR 1.2 [1.14-1.25]; P < 0.0001), infections (1.48 [1.38-1.54]; P < 0.001), acute respiratory failure (1.09 [1.03-1.15]; P = 0.006), acute kidney injury (1.12 [1.05-1.19]; P < 0.001), obstetric events (1.53 [1.66-1.81]; P < 0.0001), and neurological deficits (1.19 [1.12-1.27]; P < 0.0001). In the matched study, migrants more often required vasopressors, mechanical ventilation, and renal replacement therapy; had longer ICU stays (median 4 [2-8] vs. 4 [2-7] days; P < 0.0001) and hospital stays (10 [5-20] vs. 8 [4-15]; P < 0.0001) and had higher hospital costs (14.2 ± 23.6 vs. 13.4 ± 11.5 K€; P < 0.0001). Hospital mortality was similar (6.7% vs. 6.6%; P = 0.69).

CONCLUSION

Admissions of undocumented migrants to French ICUs doubled from 2011 to 2018. The patients were younger and, although sicker, achieved similar outcomes to those in general ICU patients.

The surfacing portion of the Iceberg of the Domestic Violence Phenomenon-data from the Israeli National Trauma Registry

Background

Domestic violence against women, which is an ancient phenomenon, is still thriving worldwide. The burden of domestic violence that is non-fatal on scene and its consequences in Israel are unknown. The purpose of this study was to provide evidence-based data regarding domestic violence-related hospitalizations among women in Israel.

Methods

The study is a retrospective cohort study of hospitalized patients included in the Israeli National Trauma Registry between January 1, 2011 and December 31, 2020. All women aged 14 and older, hospitalized due to a violence-related injury in one of the six-level I Trauma Centers or one of the 15 regional Trauma Centers in Israel were included (n = 676).

Results

Domestic violence contributes to moderate, severe, and critical injuries in a quarter of abused hospitalized women. Among these women, 20% underwent surgery, and in-hospital mortality was recorded for 2% of the patients. For most cases (53%), the spouse or ex-spouse caused the injury. The family relationship with the perpetrator was distributed differently between the population groups. The proportion of brothers who attacked sisters was greatest among Arabs (14.4%), while the phenomenon of attacking a mother was infrequent in the Arab sub-group. In contrast, among Jewish women, the proportion of those injured by a son was high, especially among the group of Jewish immigrants from the Former Soviet Union (FSU) (17%) and other countries (26%). In a multivariable logistic regression model with at least moderate injury as a dependent variable, in comparison to Israeli Arabs, Jews had a higher odds for sustaining at least moderate injuries, while the odds of Jewish immigrants not from FSU or Ethiopia were the highest (OR = 4.5, 95% CI 2.0–9.9). The annual hospitalization risk was 1.3/100,000 and 5.8/100,000, respectively for Jews and Arabs in 2020, almost fivefold higher among Arab women in comparison to Jewish women (RR = 4.6, 95% CI 2.9–7.3).

Conclusions

Domestic violence prevention should pay special attention to populations at risk, such as Arab women and new immigrants, as those women are especially vulnerable and often without sufficient family support and lack of economic resources to exit the trap of domestic violence. The collaboration between social and health services, the police, and the local authorities is crucial.

Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020

PURPOSE

Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs.

METHODS

This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis.

RESULTS

During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed.

CONCLUSIONS

Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.

Opportunities for diversifying and enriching our article mix

As 2020 comes to a close, the Israel Journal of Health Policy Research (IJHPR) will soon be starting its tenth year of publication. This editorial compares data from 2012 (the journal's first year of publication) and 2019 (the journal's most recent full year of publication), regarding the journal's mix of article types, topics, data sources and methods, with further drill-downs regarding 2019.The analysis revealed several encouraging findings, including a broad and changing mix of topics covered. However, the analysis also revealed several findings that are less encouraging, including the limited number of articles which assessed national policy changes, examined changes over time, and/or made secondary use of large-scale survey data. These findings apparently reflect, to some extent, the mix of studies being carried out by Israeli health services researchers.As the senior editors of the IJHPR we are interested in working with funders, academic institutions, the owners and principal users of relevant administrative databases, and individual scholars to further understand the factors influencing the mix of research being carried out, and subsequently published, by Israel's health services research community. This deeper understanding could then be used to develop a joint plan to diversify and enrich health services research and health policy analysis in Israel. The plan should include a policy of ensuring improved access to data, to properly support information-based research.

Health care utilisation for treatment of injuries among immigrants in Norway: a nationwide register linkage study

Background

Previous research has generally found lower rates of injury incidence in immigrant populations than in native-born populations. Most of this literature relies on mortality statistics or hospital data, and we know less about injuries treated in primary health care. The aim of the present study was to assess use of primary and secondary care for treatment of injuries among immigrants in Norway according to geographic origin and type of injury.

Methods

We conducted a nationwide register-based cohort study of all individuals aged 25–64 years who resided in Norway as of January 1st 2008. This cohort was followed through 2014 by linking sociodemographic information and injury data from primary and secondary care. We grouped immigrants into six world regions of origin and identified immigrants from the ten most frequently represented countries of origin. Six categories of injury were defined: fractures, superficial injuries, open wounds, dislocations/sprains/strains, burns and poisoning. Poisson regression models were fitted to estimate incidence rate ratios separately for injuries treated in primary and secondary care according to immigrant status, geographic origin and type of injury, with adjustment for sex, age, county of residence, marital status and socioeconomic status.

Results

Immigrants had a 16% lower incidence of injury in primary care than non-immigrants (adjusted IRR = 0.84, 95% CI 0.83–0.84), and a 10% lower incidence of injury in secondary care (adjusted IRR = 0.90, 95% CI 0.90–0.91). Immigrants from Asia, Africa and European countries outside EU/EEA had lower rates than non-immigrants for injuries treated in both primary and secondary care. Rates were lower in immigrants for most injury types, and in particular for fractures and poisoning. For a subset of injuries treated in secondary care, we found that immigrants had lower rates than non-immigrants for treatment of self-harm, falls, sports injuries and home injuries, but higher rates for treatment of assault, traffic injuries and occupational injuries.

Conclusions

Health care utilisation for treatment of injuries in primary and secondary care in Norway was lower for immigrants compared to non-immigrants. Incidence rates were especially low for immigrants originating from Asia, Africa and European countries outside EU/EEA, and for treatment of fractures, poisoning, self-harm and sports injuries.

Socio-economic disparities and returning to work following an injury

BACKGROUND

Traumatic injury is one of the main reasons for temporary and permanent occupational disability. The objective of this study was to define the role of socio-economic position on post-injury occupational absenteeism.

METHODS

This was a nationwide retrospective cohort study, based on linking The Israeli National Trauma Registry (INTR) and the National Insurance Institute (NII) databases. The study population included 44,740 injured workers (residents of Israel, aged 21-67, hospitalized between 2008 and 2013 and employed prior to injury as salaried workers). Logistic-regression models tested the probability of not returning to work (RTW).

RESULTS

The majority of the study population (61%) RTW within 1 month following the injury event. Income prior to injury was significantly associated with longer out of work stay, explaining 9% variance. A significant interaction (p value < 0.0001) was found between age and income on out of work stay more than 1 month, 1 year and 2 years. Logistic regression models of out of work stay were conducted separately for all age groups. Lower income was associated with greater chance for out of work stay for more than 1 month; and the gap between the lowest and highest income quartiles was greater among older workers (age 55+), where there was an elevenfold increase in probability of not RTW among casualties from the lowest vs. highest income quartile. In comparison to other population groups, Arabs were at greater odds of longer out of work stay following an injury. Among injured persons recognized by the NII as having occupational injuries, the odds for not RTW within a month, a year and 2 years were respectively 3.9, 2.5 and 2.2 times significantly greater in comparison to employees injured outside the workplace.

CONCLUSIONS

This study identified population groups with a high probability of not RTW following an injury requiring hospitalization. Intervention programs for injured employees should promote early rehabilitation and aim to shorten out of work stay. These programs should be ethnically adapted and focus on underprivileged and disadvantaged populations.