Shelter in Place and an Alarming Increase in Penetrating Trauma in Children and Concerning Decrease in Child Abuse

BACKGROUND

On March 14, 2020, schools across North Carolina (NC) closed in response to Covid-19, forcing completion of the school year at home. Most pediatric trauma occurs at home with a higher prevalence when children are out of school. We queried the state trauma database to assess if the 2020 "shelter in place" was associated with an increase in pediatric trauma statewide.

METHODS

The NC trauma database was queried for injuries in children (age < 18 yrs) from 13 March-1 August 2020, and the corresponding months of 2018 and 2019. The number and type of injuries were compared. We also queried the NC death certificate and child welfare databases. Data were analyzed by standard statistical methods using chi-squared or Kruskal-Wallis test.

RESULTS

Total pediatric trauma cases were lower during 2020 (71.6 per 100,000) compared to 2018 (92.4 per 100,000) and 2019 (80 per 100,000) (P < .001); however, average injury severity score (ISS) was higher (P = .001). A significant increase in firearm injuries were seen in 2020 (P = .016), with an increase in mortality (P = .08) and ISS (P = .013). The rate of child abuse trauma decreased in 2020 (P = .005) as did the number of child abuse and neglect reports (P < .001). There were also significant decreases in trauma due to sports, burns, falls, and motor vehicle accidents.

CONCLUSION

While overall pediatric trauma decreased during the Covid-19 pandemic, there was an alarming increase in penetrating injuries in children. Child abuse trauma and reports decreased, which is concerning for lower identification of abuse.

Estimated Cost-Effectiveness of Implementing a Statewide Tranexamic Acid Protocol for the Management of Suspected Hemorrhage in the Prehospital Setting

Introduction: Hemorrhage is responsible for up to 40% of all traumatic deaths. The seminal CRASH-2 trial demonstrated a reduction in overall mortality following early tranexamic acid (TXA) administration to bleeding trauma patients. Following publication of the trial results, TXA has been incorporated into many prehospital trauma protocols. However, the cost-effectiveness of widespread TXA adoption by EMS is unknown.Objective: To estimate the cost-effectiveness of statewide implementation of a TXA protocol.Methods: The North Carolina Trauma Registry was queried to identify potential TXA patients using the a priori criteria of age ≥18 years, suspected hemorrhage, penetrating or blunt injury, and prehospital blood pressure <90 mmHg and heart rate >110 bpm. Using life tables adjusted for age, sex, and race, and the absolute risk reductions in mortality with early TXA administration reported in the literature, the life-years gained were calculated for each potential life saved. Implementation costs consisted of initial stocking, training, and replacement costs. Projected reduction in hospitalization costs were based on estimates reported in the literature. Economic analyses were conducted from societal and state EMS system perspectives. To assess the robustness of the model, univariate and bivariate sensitivity analyses were performed on selected input variables.Results: Based on the TXA inclusionary criteria, 159 patients could potentially receive TXA per year. In the base-case scenario with a projected absolute mortality reduction of 3%, an additional 4.8 lives per year in NC would be saved, with an estimated 191 total life-years gained. The statewide implementation and operation cost was $305,122 in year 1, and continued operating costs were $6,042 in years 2 and 3, yielding a cost per life saved of $63,967 in year 1 and $1,267 in years 2 and 3. The cost per life-year gained was $1,595 in year 1 and $32 in years 2 and 3. Annual hospitalization costs would potentially be reduced by $1,828,072.Conclusion: Previous studies have demonstrated the clinical effectiveness of early TXA administration to patients with hemorrhage. Our modeling of the financial implications and clinical benefits of implementing a statewide TXA protocol suggests that prehospital TXA is a cost-effective treatment.

Causes of death following discharge after trauma in North Carolina

BACKGROUND

While a "fourth peak" of delayed trauma mortality has been described, limited data describe the causes of death (CODs) for patients in the years following an injury. This study investigates the difference in COD statewide for patients with and without a recent trauma admission.

METHODS

This retrospective cohort study compared COD for trauma and nontrauma patients in North Carolina. Death certificates in NC's death registry were matched with the NC trauma registry between January 2013 and December 2018 using matching on name and date of birth. Patients who died during the index trauma admission were excluded. Underlying COD recorded on the death certificate were used for the primary analysis.

RESULTS

Of 481,415 death records, 19,083 (4.0%) were linked to an alive discharge within the trauma registry during the study period. Prior trauma patients (PTPs) had a higher incidence of mental illness (9.2 vs. 6.1%), Alzheimer's (6.1% vs. 4.2%), and opioid-related (1.8% vs. 1.6%) COD compared to nontrauma patients, p < 0.05. Overall, suicide was higher in the nontrauma cohort (1.5% vs. 1.1%); however, PTP had higher incidences of death by motor vehicle collision and other injury (6.0% vs. 3.8%) and homicide (0.9% vs. 0.6%), p < 0.001. Prior trauma patients had 1.16 increased odds of an opioid-related death (p = 0.009; 95% confidence interval, 1.04-1.29) compared with those without prior trauma. Younger PTP had a much higher rate of death from suicide (12.0%) compared with those 41 to 65 years (2.8%) and older than 65 years (0.2%; p < 0.001). Discharge to skilled nursing facility (odds ratio, 1.87; p < 0.05) and severe injury (odds ratio, 1.93; p < 0.05) were associated with early death after discharge (≤90 days).

CONCLUSION

After hospital discharge, PTPs remain at risk of dying from future trauma and opioid-related conditions. Prevention strategies for PTP should address the increased risk of death from a subsequent traumatic injury and the at-risk populations for early death after discharge.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level IV.

Prolonged Emergency Department Stay at Referring Facilities: A Poor Trauma Performance Improvement Tool

BACKGROUND

Delays in the transfers of injured patients are perceived to increase morbidity and mortality and drive initiatives to limit the emergency department length of stay (LOS) at referring facilities (RF). RF LOS >4 hours is used for performance improvement (PI) with a large review burden with few improvement opportunities.

METHODS

A statewide trauma registry 2013-2018 was used. Descriptive and inferential statistics including logistic regression were used to evaluate nongeriatric adult patients with ED LOS <12 hours. Paired data analyses utilizing prehospital (PH) and RF variables, vital signs (VS), Glasgow Coma Score-Motor component (GCS-M), RF LOS, mortality, trauma center hospital LOS (HLOS), and intensive care unit (ICU) LOS were performed.

RESULTS

13,721 of 56,702 transfer patients were selected. Mortality fell over time in all abbreviated injury score groups. GCS-M and systolic blood pressure (SBP) were correlated with mortality in both prehospital and RF data and highest in patients with abnormal GCS-M or SBP in both settings (38.0%, 30.1%). Examination of mortality over time in the group with abnormal VS showed SBP as the only variable with increasing mortality related to RF LOS. Average HLOS and ICU LOS were longest in patients with abnormal PH and RF SBP and GCS-M.

DISCUSSION

Support for PI evaluation of RF LOS >4 hours was not identified. Increased survival over time is explained by early transfers of high mortality patients. Our data support existing efficient statewide transfers and recommend PI review of transfer patients with abnormal GCS-M and SBP in a narrower timeframe.

Evaluation of statewide utilization of helicopter emergency medical services for interfacility transfer

BACKGROUND

Helicopter emergency medical services (HEMSs) are used with increasing frequency for the transportation of injured patients from the scene and from treatment facilities to higher levels of care. Improved outcomes have been difficult to establish, and reports of overutilization and financial harm have been published. Our study was performed to evaluate statewide utilization for interfacility transfers (IFTs).

METHODS

Data from the North Carolina state trauma registry from 2013 to 2017 were evaluated and ground, and helicopter IFTs were compared.

RESULTS

Overall interfacility use of HEMSs peaked at 7,861 patient transports in 2016, and the percent of all IFTs fell from 17% to 13.3% over the study period. Helicopter emergency medical services patients were more likely to be male (69.8%) and younger (48.0 vs. 56.2 years), and have higher Injury Severity Scores (14.6 vs. 9.0) and higher mortality (10.5% vs. 2.8%) than ground emergency medical services (GEMSs) patients. When adjusted for age, sex, Injury Severity Score, and transport distance, HEMSs survival was significantly higher (odds ratio, 0.353; 95% CI, 0.308-0.404; p < 0.0001). Normal prehospital vital signs (VSs) and Glasgow Coma Scale score motor component (GCS-M) were associated with low mortality rates in both groups. Abnormal prehospital VSs and GCS-M were associated with an 11.8% mortality rate in HEMSs patients and 3.1% in GEMSs patients. Normal referring facility VSs and GCS-M did not confer similar protection with a mortality rate of 10.0% in HEMSs patients and 2.8% in GEMSs. Changes in prehospital to referring facility VSs did not demonstrate a low mortality group. Abbreviated Injury Scale and changes in VSs did not identify HEMSs transport benefit groups.

CONCLUSION

The proportion of HEMSs transfers fell over the study period and, while associated with a 10.5% mortality rate, had an outcome benefit compared with GEMSs. These patients could not be sorted into risk categories for transportation choice based on VSs or GCS-M derangement or by changes thereof, and opportunities for system improvement were not identified.

LEVEL OF EVIDENCE

Prognostic/epidemiological study, level III; Care Management, level IV.

Opioid Prescribing in the Pediatric Orthopaedic Trauma Population

The purpose of this article is to describe opioid prescribing patterns for children with orthopaedic injuries. A retrospective chart review was conducted on pediatric orthopaedic trauma patients (n = 124) who were discharged from the hospital or emergency department or had a clinic visit during a 1-month period. Patient demographics, prescription specifics, injury details, and fracture fixation information were collected. Results show that most children received opioids after injury (82.3%). While children undergoing operative fixation typically received opioids, only 39.5% with closed reduction did. Hydrocodone- acetaminophen accounted for 93% of prescriptions, but adolescents were more likely to receive other drugs. There was a significant trend of increasing daily dosage with increased age; 36.73% of adolescents received > 50 morphine milligram equivalents per day. Children with orthopaedic injuries are typically prescribed opioids; older children more commonly receive higher dosages. Further study is needed to define prescribing trends across facility and specialty types to aid in development of standardized prescribing guidelines. (Journal of Surgical Orthopaedic Advances 27(4):269-273, 2018).

The use of a prescription drug monitoring program to develop algorithms to identify providers with unusual prescribing practices for controlled substances

The misuse, abuse and diversion of controlled substances have reached epidemic proportion in the United States. Contributing to this problem are providers who over-prescribe these substances. Using one state's prescription drug monitoring program, we describe a series of metrics we developed to identify providers manifesting unusual and uncustomary prescribing practices. We then present the results of a preliminary effort to assess the concurrent validity of these algorithms, using death records from the state's vital records database pertaining to providers who wrote prescriptions to patients who then died of a medication or drug overdose within 30 days. Metrics manifesting the strongest concurrent validity with providers identified from these records related to those who co-prescribed benzodiazepines (e.g., valium) and high levels of opioid analgesics (e.g., oxycodone), as well as those who wrote temporally overlapping prescriptions. We conclude with a discussion of a variety of uses to which these metrics may be put, as well as problems and opportunities related to their use.

Injury prevention: North Carolina's challenge and capacity to respond

North Carolina has worked to develop an infrastructure and identify priorities to reduce the high morbidity and mortality from injuries. Findings of the North Carolina Institute of Medicine (NCIOM) Task Force on Adolescent Health and the NCIOM Task Force on Prevention, combined with the North Carolina Division of Public Health strategic plan and the Injury and Violence Prevention State Advisory Council, have laid the path toward this goal.

Homicide among pregnant and postpartum women in the United States: a review of the literature

Eighteen articles that examined the extent of homicide among pregnant and/or postpartum women in the United States are reviewed, documenting the studies' methods and findings. Results from proportional mortality analyses (studies that examined only deaths, rather than deaths within a larger population of living individuals) showed a modicum of support for the contention that homicide may account for a greater proportion of the deaths among pregnant/postpartum women than among other women of reproductive age. However, results from more comprehensive analyses that estimated homicide risks/rates (studies that examined deaths within the context of living populations) did not find any evidence to suggest that pregnant/postpartum women experience a greater risk/rate of homicide compared to other women of reproductive age. This difference in findings is discussed in light of the different methodological approaches.

The choline/creatine ratio in five benign neoplasms: comparison with squamous cell carcinoma by use of in vitro MR spectroscopy

BACKGROUND AND PURPOSE

The choline (Cho)/creatine (Cr) ratio has been shown to be a reliable proton MR spectroscopy metabolic marker for differentiating squamous cell carcinoma (SCCA) from normal muscle in the upper aerodigestive tract. However, it is unclear whether the Cho/Cr ratio can be used to differentiate a malignant tumor from a benign neoplasm in the extracranial head and neck. Our purpose was to determine whether the Cho/Cr ratio can be used to differentiate benign from malignant tumors in this region.

METHODS

In vitro one-dimensional proton MR spectroscopy (2,000/136,272 [TR/TE]) was performed at 11 T on tissue specimens obtained from glomus tumors (n = 3), inverting papilloma (n = 1), and schwannoma (n = 1). Cho/Cr area ratios were calculated and compared with similar, previously reported in vitro (11 T) findings and with samples of SCCA and normal muscle.

RESULTS

The Cho/Cr ratio was elevated in relation to muscle in all benign tumors at TE = 136 (glomus tumors = 4.52, inverting papilloma = 3.85, schwannoma = 2.2) and at TE = 272 (glomus tumors = 8.01, inverting papilloma = 2.1, schwannoma = 4.28). The average Cho/Cr ratio for benign lesions was 3.92 (TE = 136) and 6.11 (TE = 272). The Cho/Cr ratio was significantly higher in benign tumors than in both SCCA and muscle. The average Cho/Cr ratio for muscle at TEs of 136 and 272 was 1.16 and 1.31, respectively, whereas for SCCA the average Cho/Cr ratio at TEs of 136 and 272 was 1.67 and 2.45, respectively.

CONCLUSION

In our small group, the Cho/Cr ratio was significantly higher in benign tumors than in muscle and SCCA of the extracranial head and neck.

Proton MR spectroscopy of squamous cell carcinoma of the extracranial head and neck: in vitro and in vivo studies

PURPOSE

To determine the ability of in vitro one-dimensional and two-dimensional proton MR spectroscopy to help differentiate squamous cell carcinoma of the extracranial head and neck from normal tissues and to correlate the in vitro observations with clinical studies.

METHODS

In vitro 1-D and 2-D correlated proton MR spectroscopy (11 T) was performed in tissue specimens of squamous cell carcinoma of the head and neck (n = 19), in normal tissue (n = 13), in metastatic cervical lymph nodes (n = 3), and in a squamous cell carcinoma cell line. In vivo 1-D proton MR spectroscopy (1.5 T) was performed in patients with squamous cell carcinoma (n = 7) and in healthy volunteers (n = 7). The ratio of the areas under the choline (Cho) and creatine (Cr) resonances were calculated for 1-D proton MR spectra for the in vitro tissue studies and correlated with the in vivo studies. Data from in vitro 2-D correlated spectroscopy were analyzed for differences in the presence or absence of various metabolites in samples of tumor and normal tissue. Statistical analysis consisted of 2 x 2 factorial repeated measures analysis of variance (ANOVA), discriminate analysis, and chi2 test.

RESULTS

The mean in vitro 1-D proton MR spectroscopic Cho/Cr ratio was significantly higher in tumor than in normal tissue. The difference between the mean ratios appeared to increase with increasing echo time. All in vivo tumor Cho/Cr ratios were greater than the calculated mean in vitro tumor ratio, whereas six of the seven volunteers had no detectable Cho and Cr resonances. Two-dimensional correlated MR spectroscopic data revealed that a variety of amino acids have a significantly greater likelihood of being detected in tumor than in normal tissues.

CONCLUSIONS

One-dimensional and 2-D proton MR spectroscopy can help differentiate primary squamous cell carcinoma and nodal metastases containing squamous cell carcinoma from normal tissue both in vitro and in vivo. In addition, 2-D spectroscopy can help identify the presence of certain amino acids in squamous cell carcinoma that are not detected in normal tissue.

Proton MR spectroscopy of squamous cell carcinoma of the upper aerodigestive tract: in vitro characteristics

PURPOSE

To determine the ability of in vitro high-field-strength proton MR spectroscopy to differentiate squamous cell carcinoma of the upper aerodigestive tract from uninvolved muscle.

METHODS

Surgical specimens of squamous cell carcinoma arising from the upper aerodigestive tract (n = 18) and from muscle (n = 13) were examined in vitro using high-field (11 T) proton MR spectroscopy. The peak heights of choline and creatine were measured for tumor and muscle at echo times of 136 and 272. The choline/creatine (Cho/Cr) ratio was compared between tumor and normal tissue for each echo time. Student's t test was used to determine whether a significant difference existed between proton MR spectroscopic measurements of the Cho/Cr ratio for tumor and muscle.

RESULTS

The mean Cho/Cr ratio was consistently higher in tumor than in muscle at all echo times; however, statistically significant differences between tumor and muscle were identified only at longer echo times (136 and 272).

CONCLUSION

The Cho/Cr peak height ratio can be used to differentiate tumor from muscle in vitro (at 11 T).

Squamous cell carcinomas that arise in the oral cavity and tongue base: can CT help predict perineural or vascular invasion?

PURPOSE

To determine the ability to use computed tomography (CT) to predict invasion of adjacent nerves or vessels by oral cavity tumors.

MATERIALS AND METHODS

Contrast material-enhanced CT scans and histopathologic reports were retrospectively reviewed in 48 patients (36 men, 12 women) aged 38-75 years who underwent gross total resection of squamous cell carcinomas arising in the tongue, the base of the tongue, and the floor of the mouth. CT criteria for diagnosis of perineural or vascular invasion were aggressive tumor margins, invasion of the sublingual space, and direct adjacency of the tumor to the enhanced lingual vasculature in the sublingual space. CT and histopathologic findings of perineural and/or vascular invasion by tumor were correlated in all patients.

RESULTS

With the above criteria, CT findings predictive of perineural or vascular invasion had a sensitivity of 88%; specificity, 83%; positive predictive value, 85%; and negative predictive value, 84%.

CONCLUSION

CT findings can be used to predict perineural or vascular invasion by oral cavity tumors.

Proton MR spectroscopy in a possible enhancing hamartoma in a patient with neurofibromatosis type 1

A patient with neurofibromatosis type 1 was found to have an enhancing lesion in the cerebellum. Proton MR spectroscopy was performed and showed findings similar to those seen in healthy volunteers. A 3-year follow-up MR study showed the lesion was unchanged. Proton MR spectroscopy might prove useful in the diagnosis of hamartomas.

Proton MR spectroscopy in patients with neurofibromatosis type 1: evaluation of hamartomas and clinical correlation

PURPOSE

To use proton MR spectroscopy in patients with neurofibromatosis type 1 to determine: (a) the spectroscopic characteristics of hamartomas and compare them with that of gliomas; (b) whether differences exist between patients with and without learning disabilities; and (c) spectroscopic patterns in normal-appearing brain (by MR imaging) in patients with and without focal lesions.

METHODS

Seventeen proton MR spectroscopy volumes were obtained in 10 patients with neurofibromatosis type 1 (including hamartomas, N = 7; normal-appearing brain, N = 10). Seven patients had learning disorders, and 3 were mentally normal. Ten healthy volunteers and 10 patients with pathologically proved gliomas (all grades) were also examined. N-Acetyl aspartate/creatine, creatine/choline, and N-acetyl aspartate/choline ratios were calculated for all samples.

RESULTS

(a) Hamartomas showed higher N-acetyl aspartate/creatine, creatine/choline, and N-acetyl aspartate/choline ratios than gliomas. Hamartomas showed N-acetyl aspartate/creatine, creatine/choline, and N-acetyl aspartate/choline ratios similar to those of healthy volunteers. (b) No significant differences in N-acetyl aspartate/creatine, creatine/choline, and N-acetyl aspartate/choline ratios were found in patients who had neurofibromatosis type 1 with and without learning disabilities. (c) N-acetyl aspartate/creatine, creatine/choline, and N-acetyl aspartate/choline ratios were similar for patients who had neurofibromatosis type 1 with and without focal hamartomas and in healthy volunteers.

CONCLUSIONS

(a) Hamartomas have a proton MR spectroscopy pattern different from that of glioma and similar to that of normal brain. (b) As performed in this study, proton MR spectroscopy did not show significant differences in patients who had neurofibromatosis type 1 with and without learning disabilities. (c) Patients who have neurofibromatosis type 1 with and without hamartomas seem to have normal intervening brain by proton MR spectroscopy when compared with healthy volunteers.