Urban-rural differences in pediatric traumatic head injuries: A prospective nationwide study

Epidemiology and outcomes of brain trauma in rural and urban populations: a systematic review and meta-analysis

OBJECTIVE

To identify and describe differences in demographics, injury characteristics, and outcomes between rural and urban patients suffering brain injury.

DATA SOURCES

CINAHL, Emcare, MEDLINE, and Scopus.

REVIEW METHODS

A systematic review and meta-analysis of studies comparing epidemiology and outcomes of rural and urban brain trauma was conducted in accordance with PRISMA and MOOSE guidelines.

RESULTS

36 studies with ~ 2.5-million patients were included. Incidence of brain injury was higher in males, regardless of location. Rates of transport-related brain injuries, particularly involving motorized vehicles other than cars, were significantly higher in rural populations (OR:3.63, 95% CI[1.58,8.35], p = 0.002), whereas urban residents had more fall-induced brain trauma (OR:0.73, 95% CI[0.66,0.81], p < 0.00001). Rural patients were 28% more likely to suffer severe injury, indicated by Glasgow Coma Scale (GCS)≤8 (OR:1.28, 95% CI[1.04,1.58], p = 0.02). There was no difference in mortality (OR:1.09, 95% CI[0.73,1.61], p = 0.067), however, urban patients were twice as likely to be discharged with a good outcome (OR:0.52, 95% CI[0.41,0.67], p < 0.00001).

CONCLUSIONS

Rurality is associated with greater severity and poorer outcomes of traumatic brain injury. Transport accidents disproportionally affect those traveling on rural roads. Future research recommendations include addition of prehospital data, adequate follow-up, standardized measures, and sub-group analyses of high-risk groups, e.g. Indigenous populations.

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.

Estimating the global incidence of traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.

METHODS

Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.

RESULTS

Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.

CONCLUSIONS

Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Spectrum and Outcome of Moderate Pediatric Head Injury Patients Admitted to Main Tertiary Hospital in Northern Jordan Border Hosting City During Strain Period of Syrian Crises

Aims and Background:

To evaluate and compare Health-Related Quality of Life (HRQoL) and disability outcome in pediatric moderate Traumatic Brain Injury (TBI) according to age, brain CT findings and treatment. The outcome could be different for none-war children in the border hosting community when health system under strain from Syrian crises.

Methods:

The HRQoL scores of 43 children with moderate TBI and abnormal brain CT, aged 8-12(n=24) and 13-18 (n=19) years at the time of injury were assessed using the Pediatric QOL Inventory, child self-report version (PedsQL). Group I (n=18) is surgically treated compared to group II (n=25) being medically treated. Disability, injury mechanism was compared.

Results:

Mean (SD) age was 12.2 (3.1) year. Based on treatment, the two groups differed only in the number of admission days (p= 0.009) with no significant difference in mean disability outcome and mean QoL in all domains. Based on age, older children (13-18 year) had better psychosocial health than younger children (8-12 year). Falling down, sport and recreational activity predominate as a mechanism of injury followed by a pedestrian. The acute epidural hematoma was the most common CT scan finding in the operative group (n=17) whereas, contusions were the most common in non-operative.

Conclusion:

This initial work could enhance research outcome from border hosting community that may suffer strain on the health sector and personal in periods of refugee influx and sudden population increase though they are not directly affected by the conflict crises. Single-incident moderate TBI where the diffuse axonal injury is absent or limited based on injury mechanism and severity has a good long-term outcome in children.

Urban/Rural disparities in Oregon pediatric traumatic brain injury

Background

Traumatic brain injury (TBI) greatly contributes to morbidity and mortality in the pediatric population. We examined potential urban/rural disparities in mortality amongst Oregon pediatric patients with TBI treated in trauma hospitals.

Methods

We conducted a retrospective study of children ages 0–19 using the Oregon Trauma Registry for years 2009–2012. Geographic location of injury was classified using the National Center for Health Statistics Urban/Rural Classification Scheme. Incidence rates were calculated using Census data for denominators. Associations between urban/rural injury location and mortality were assessed using multivariable logistic regression, controlling for potential confounders. Generalized estimating equations were used to help account for clustering of data within hospitals.

Results

Of 2794 pediatric patients with TBI, 46.6 % were injured in large metropolitan locations, 24.8 % in medium/small metropolitan locations, and 28.6 % in non-metropolitan (rural) locations. Children with rural locations of injury had a greater annualized TBI incidence rate, at 107/100,000 children per year, than those from large metropolitan areas (71/100,000 per year). Compared to children injured in urban locations, those in rural locations had more than twice the crude odds of mortality (odds ratio [OR], 2.5; 95 % CI, 1.6–4.0). This association remained significant (OR, 1.8; 95 % CI, 1.04–3.3) while adjusting for age, gender, race, insurance status, injury severity, and type of TBI (blunt vs. penetrating).

Conclusion

We observed higher rates of TBI and greater proportions of severe injury in rural compared to urban areas in Oregon. Rural children treated in the trauma system for TBI were more likely to die than urban children after controlling for demographic and injury factors associated with urban/rural residence. Further research is needed to examine treatment disparities by urban/rural location. Future work should also identify interventions that can reduce risk of TBI and TBI-related mortality among children, particularly those who live in rural areas.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-015-0063-2) contains supplementary material, which is available to authorized users.

Long-term outcome of medically confirmed and self-reported early traumatic brain injury in two nationwide samples

PRIMARY OBJECTIVES

To assess long-term effects of early traumatic brain injury (TBI) on mental health, cognition, behaviour and adjustment and to identify prognostic factors.

METHODS AND PROCEDURES

A 1-year nationwide cohort of all 0-19 year old Icelandic children and adolescents diagnosed with TBI in 1992-1993 (n = 550) received a questionnaire with clinical outcome scales and questions on TBI and socio-economic status (SES) by mail ∼16 years post-injury. A control group (n = 1232), newly selected from the National Registry, received the same questionnaire. Non-respondents answered a shorter version by telephone. Overall participation was 67%.

MAIN OUTCOMES AND RESULTS

Medically confirmed and self-reported TBI was reflected in worse outcome. Force of impact, number and severity of TBIs predicted poorer results. Parental SES and demographic factors had limited effects. Not reporting early, medically confirmed TBI did not exclude cognitive sequelae. In self-reported disability, absence of evaluation for compensation was not linked to outcome.

CONCLUSIONS

Clinical outcome was consistent with late complaints attributed to early TBI. TBI-related variables had greater prognostic value than other factors. Self-reporting of TBI sustained very early in life needs supplementary information from parents and medical records. More consistency in compensation evaluations following paediatric TBI is indicated.

Paediatric trauma mortality in Norway: a population-based study of injury characteristics and urban-rural differences

INTRODUCTION

Paediatric injury is a major global public health challenge. Epidemiological research is required for effective primary injury prevention and to develop trauma systems for optimal management of childhood injuries. This study aimed to describe the characteristics and geographical distribution of paediatric trauma deaths and to assess the relationship between rural locations and mortality rates.

MATERIALS AND METHODS

By accessing national registries, all trauma related deaths of persons aged 0-15 years in Norway from 1998 to 2007 were included. Paediatric trauma mortality rates and injury characteristic were analysed in relation to three different measures of municipal rurality: centrality, population density and settlement density.

RESULTS

There were 462 trauma related deaths during the study period and the national annual paediatric mortality rate was 4.81/100000. Rural areas had higher mortality rates, and this difference was best predicted by municipal centrality. Rural trauma was characterised by traffic accidents and deaths that occurred prior to reaching hospital. The rural and northernmost county, Finnmark, had a mortality rate three times the national average.

CONCLUSION

Mortality rates after childhood injury are high in rural areas. Substantiated measures of rurality are required for optimal allocation of primary and secondary preventive measures.

Charges associated with pediatric head injuries: a five year retrospective review of 41 pediatric hospitals in the US

Background:

Brain injuries are a significant public health problem, particularly among the pediatric population. Brain injuries account for a significant portion of pediatric injury deaths, and are the highest contributor to morbidity and mortality in the pediatric and young adult populations. Several studies focus on particular mechanisms of brain injury and the cost of treating brain injuries, but few studies exist in the literature examining the highest contributing mechanisms to pediatric brain injury and the billed charges associated with them.

Methods:

Data were extracted from the Pediatric Health Information System (PHIS) from member hospitals on all patients admitted with diagnosed head injuries and comparisons were made between ICU and non-ICU admissions. Collected data included demographic information, injury information, total billed charges, and patient outcome.

Results:

Motor vehicle collisions, falls, and assaults/abuse are the three highest contributors to brain injury in terms of total numbers and total billed charges. These three mechanisms of injury account for almost $1 billion in total charges across the five-year period, and account for almost half of the total charges in this dataset over that time period.

Conclusions:

Research focusing on brain injury should be tailored to the areas of the most pressing need and the highest contributing factors. While this study is focused on a select number of pediatric hospitals located throughout the country, it identifies significant contributors to head injuries, and the costs associated with treating them.

Genome-wide two-locus epistasis scans in prostate cancer using two European populations

Approximately 40 single nucleotide polymorphisms (SNPs) that are associated with prostate cancer (PCa) risk have been identified through genome-wide association studies (GWAS). However, these GWAS-identified PCa risk-associated SNPs can explain only a small proportion of heritability (~13%) of PCa risk. Gene-gene interaction is speculated to be one of the major factors contributing to the so-called missing heritability. To evaluate the gene-gene interaction and PCa risk, we performed a two-stage genome-wide gene-gene interaction scan using a novel statistical approach named "Boolean Operation-based Screening and Testing". In the first stage, we exhaustively evaluated all pairs of SNP-SNP interactions for ~500,000 SNPs in 1,176 PCa cases and 1,101 control subjects from the National Cancer Institute Cancer Genetic Markers of Susceptibility (CGEMS) study. No SNP-SNP interaction reached a genome-wide significant level of 4.4E-13. The second stage of the study involved evaluation of the top 1,325 pairs of SNP-SNP interactions (P(interaction) <1.0E-08) implicated in CGEMS in another GWAS population of 1,964 PCa cases from the Johns Hopkins Hospital (JHH) and 3,172 control subjects from the Illumina iControl database. Sixteen pairs of SNP-SNP interactions were significant in the JHH population at a P(interaction) cutoff of 0.01. However, none of the 16 pairs of SNP-SNP interactions were significant after adjusting for multiple tests. The current study represents one of the first attempts to explore the high-dimensional etiology of PCa on a genome-wide scale. Our results suggested a list of SNP-SNP interactions that can be followed in other replication studies.

Urban vs rural pediatric trauma in Alberta: where can we focus on prevention?

PURPOSE

Understanding differences between rural and urban pediatric trauma is important in establishing preventative strategies specific to each setting.

METHODS

Data were extracted from a Provincial Pediatric Trauma Registry on pediatric patients (0-17 years) with Injury Severity Scores (ISS) 12 or more, treated from 1996 to 2006 at 5 major trauma centers in the province. Urban and rural patients were compared with respect to demographic data, as well as injury type and severity. Statistical analysis was made using SPSS software (SPSS Inc, Chicago, Ill) by chi(2), Fisher's Exact test, or t test with P < .05 considered significant.

RESULTS

Of n = 2660, 63.3% rural patients predominate; mean ISS was 22.5. However, rural patients had more severe injuries (ISS, 23.2 vs 21.8; P < .0001). Blunt trauma was the most common mechanism overall (urban, 89.6%; rural, 93.2%), with most being motor vehicle accidents (MVAs). Significantly, more penetrating trauma occurred in the urban setting (5.4% vs 2.6%; P < .0001). Intent injuries were more common in the urban setting (15.2% vs 5.5%). Of the patients, 89.2% survived the trauma. However, urban patients had a higher rate of death than rural ones (13.0% vs 10.5%; P < .05).

CONCLUSION

Despite the finding that rural patients sustained more severe injuries, overall survival was actually better when compared with urban patients. Most injuries were blunt trauma, suggesting road safety should be the main target in prevention strategies. Intent injuries were much higher in the urban group, thus, a need to target violence in urban prevention strategies.

The prognostic value of injury severity, location of event, and age at injury in pediatric traumatic head injuries

AIMS

To estimate the prognostic value of injury severity, location of event, and demographic parameters, for symptoms of pediatric traumatic head injury (THI) 4 years later.

METHODS

Data were collected prospectively from Reykjavik City Hospital on all patients age 0-19 years, diagnosed with THI (n = 408) during one year. Information was collected on patient demographics, location of traumatic event, cause of injury, injury severity, and ICD-9 diagnosis. Injury severity was estimated according to the Head Injury Severity Scale (HISS). Four years post-injury, a questionnaire on late symptoms attributed to the THI was sent.

RESULTS

Symptoms reported were more common among patients with moderate/severe THI than among others (p < 0.001). The event location had prognostic value (p < 0.05). Overall, 72% of patients with moderate/severe motor vehicle-related THI reported symptoms. There was a curvilinear age effect (p < 0.05). Symptoms were least frequent in the youngest age group, 0-4 years, and most frequent in the age group 5-14 years. Gender and urban/rural residence were not significantly related to symptoms.

CONCLUSIONS

Motor vehicle related moderate/severe THI resulted in a high rate of late symptoms. Location had a prognostic value. Patients with motor vehicle-related THI need special consideration regardless of injury severity.