No abstract

Seattle City Council and University of Washington Royalty Research Fund.

Objective: To determine if higher fresh frozen plasma (FFP) and platelet to packed red blood cell (PRBC) ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients.

Objective: To evaluate morbidity and mortality among critically injured children with acute respiratory distress syndrome (ARDS) Design: Retrospective cohort study Setting: 460 Level I/II adult or pediatric trauma centers contributing to the National Trauma Data Bank Patients: 146,058 patients <18 years admitted to an intensive care unit with traumatic injury from 2007-2016 Interventions: None Measurements and Main Results: We assessed in-hospital mortality and need for postdischarge care among patients with and without ARDS, and hospital resource utilization and discharge disposition among survivors. Analyses were adjusted for underlying mortality risk (age, Injury Severity Score, serious brain or chest injury, and admission heart rate and hypotension), and year, transfer status, and facility trauma level designation. ARDS occurred in 2590 patients (1.8%). Mortality was 20.0% among ARDS patients versus 4.3% among non-ARDS patients, with an adjusted relative risk (aRR) of 1.76 (95% CI 1.52-2.04). Post-discharge care was required in an additional 44.8% of ARDS patients versus 16.0% of non-ARDS patients (aRR 3.59, 2.87-4.49), with only 35.1% of ARDS patients discharging to home versus 79.8% of non-ARDS patients. ARDS mortality did not change over the ten-year study period (aRR 1.

Abstract Background and aims Chronic pain after traumatic injury and surgery is highly prevalent, and associated with substantial psychosocial co-morbidities and prolonged opioid use. It is currently unclear whether predicting chronic post-injury pain is possible. If so, it is unclear if predicting chronic post-injury pain requires a comprehensive set of variables or can be achieved only with data available from the electronic medical records. In this prospective study, we examined models to predict pain at the site of injury 3–6 months after hospital discharge among adult patients after major traumatic injury requiring surgery. Two models were developed: one with a comprehensive set of predictors and one based only on variables available in the electronic medical records. Methods We examined pre-injury and post-injury clinical variables, and clinical management of pain. Patients were interviewed to assess chronic pain, defined as the presence of pain at the site of injury. Prediction models were developed using forward stepwise regression, using follow-up surveys at 3–6 months. Potential predictors identified a priori were: age; sex; presence of pre-existing chronic pain; intensity of post-operative pain at 6 h; in-hospital opioid consumption; injury severity score (ISS); location of trauma, defined as body region; use of regional analgesia intra- and/or post-operatively; pre-trauma PROMIS Depression, Physical Function, and Anxiety scores; in-hospital Widespread Pain Index and Symptom Severity Score; and number of post-operative non-opioid medications. After the final model was developed, a reduced model, based only on variables available in the electronic medical record was run to understand the “value add” of variables taken from study-specific instruments. Results Of 173 patients who completed the baseline interview, 112 completed the follow-up within 3–6 months. The prevalence of chronic pain was 66%. Opioid use increased from 16% pre-injury to 28% at 3–6 months. The final model included six variables, from an initial set of 24 potential predictors. The apparent area under the ROC curve (AUROC) of 0.78 for predicting pain 3–6 months was optimism-corrected to 0.73. The reduced final model, using only data available from the electronic health records, included post-surgical pain score at 6 h, presence of a head injury, use of regional analgesia, and the number of post-operative non-opioid medications used for pain relief. This reduced model had an apparent AUROC of 0.76, optimism-corrected to 0.72. Conclusions Pain 3–6 months after trauma and surgery is highly prevalent and associated with an increase in opioid use. Chronic pain at the site of injury at 3–6 months after trauma and surgery may be predicted during hospitalization by using routinely collected clinical data. Implications If our model is validated in other populations, it would provide a tool that can be easily implemented by any provider with access to medical records. Patients at risk of developing chronic pain could be selected for studies on preventive strategies, thereby concentrating the interventions to patients who are most likely to transition to chronic pain.

Objectives. We investigated whether stricter state-level firearm legislation was associated with lower hospital discharge rates for nonfatal firearm injuries. Methods. We estimated discharge rates for hospitalized and emergency department–treated nonfatal firearm injuries in 18 states in 2010 and used negative binomial regression to determine whether strength of state firearm legislation was independently associated with total nonfatal firearm injury discharge rates. Results. We identified 26 744 discharges for nonfatal firearm injuries. The overall age-adjusted discharge rate was 19.0 per 100 000 person-years (state range = 3.3–36.6), including 7.9 and 11.1 discharges per 100 000 for hospitalized and emergency department–treated injuries, respectively. In models adjusting for differences in state sociodemographic characteristics and economic conditions, states in the strictest tertile of legislative strength had lower discharge rates for total (incidence rate ratio [IRR] = 0.60; 95% confidence interval [CI] = 0.44, 0.82), assault-related (IRR = 0.58; 95% CI = 0.34, 0.99), self-inflicted (IRR = 0.18; 95% CI = 0.14, 0.24), and unintentional (IRR = 0.53; 95% CI = 0.34, 0.84) nonfatal firearm injuries. Conclusions. There is significant variation in state-level hospital discharge rates for nonfatal firearm injuries, and stricter state firearm legislation is associated with lower discharge rates for such injuries.

In the last few years, substantial attention has been given to the problem of sports-related traumatic brain injury, including concussion. Most of the research has focused on athletes at the professional and collegiate levels, with limited studies conducted among youth athletes. The Institute of Medicine 1 produced a consensus report on sports-related concussions (SRCs) in youths, which reviewed the existing literature on the topic and made general recommendations about areas for further research. However, this report was released more than 5 years ago, and it did not provide specific recommendations to guide youth athletes and their families, medical professionals, and athletic personnel and organizations. The latest Consensus Statement on Concussion in Sport 2 addressed some of the pertinent issues regarding SRCs incurred by younger athletes. The recent Centers for Disease Control and Prevention guidelines 3 on mild traumatic brain injury among children and adolescents focused on the diagnosis, prognosis, and management of these injuries but did not include any recommendations related to prevention.Concerns about concussions in youth athletes are occurring against the backdrop of an obesity epidemic among children and adolescents in the United States and many high-income countries, owing in part to increases in screen time and sedentary behavior. 4 The 2018 Physical Activity Guidelines for Americans by the US Department of Health and Human Services 4 examined the evidence for and benefits of health-related physical activity across the lifespan, recommending moderate to vigorous physical activity every day and vigorous activity at least 3 times per week.Organized sports offer a way for children and adolescents to engage in moderate to vigorous physical activity, but fear of injury may cause some parents to choose not to enroll their children in contact or collision sports, which may lead to fewer children meeting the recommended guidelines for physical activity. Thus, understanding what the scientific evidence tells us about the risk of injury is important for youth athletes and their families.Given the importance of SRCs among youth athletes, the rapid progression of research on this topic during the last decade, and the need to provide further guidance to youth athletes and their families, medical professionals, and athletic personnel and organizations, we undertook a consensus process to summarize the current literature from January 1, 1980, through December 31, 2018, and provide recommendations regarding the prevention, assessment, and management of SRCs in youth athletes. MethodsA consensus panel was created to represent a broad spectrum of expertise in the fields of youth sports and concussion. This panel IMPORTANCE Given the importance of sports-related concussions among youth athletes, the rapid progress of research on this topic over the last decade, and the need to provide further guidance to youth athletes, their families, medical professionals, and athletic personnel and organizations, a panel of exp...

BackgroundTraumatic brain injury (TBI) is a major public health problem and a leading cause of death worldwide. A paucity of literature exists on risk factors for mortality in isolated severe TBI, a condition that is distinct from severe TBI in the setting of multisystem trauma. We determined risk factors for in-hospital mortality in this patient population.MethodsWe conducted a retrospective cohort study using data from the National Trauma Databank from 2008–2012 to study all patients admitted with a diagnosis of severe TBI, excluding children, patients with non-isolated TBI, transfers, and hospitalization <48 h. We used multivariable Poisson regression to analyze the association between demographic, clinical, and facility-level characteristics and in-hospital mortality.ResultsA total of 41,590 patients were included in our analysis. The cumulative incidence of in-hospital mortality was 10.2 %. In multivariable analysis, older age (RR 3.92, 95 % CI 3.54–4.34), male gender (RR 1.17, 95 % CI 1.09–1.25), admission hypotension (RR 1.83, 95 % CI 1.61–2.09), the need for mechanical ventilation (RR 4.18, 95 % CI 3.64–4.80), higher injury severity score (RR 1.86, 95 % CI 1.41–2.45), and poor initial neurologic grade (RR 3.06, 95 % CI 2.74–3.43) were associated with a higher risk for mortality.ConclusionsAdmission hypotension and the need for mechanical ventilation were possible modifiable risk factors associated with increased in-hospital mortality following isolated severe TBI. Although risk factors for mortality are similar in isolated and non-isolated TBI, the underlying etiologies for hypotension and respiratory failure are likely different in both conditions and require further exploration.