Unintentional Traumatic Injury Research Articles

Change In Fall Risk-Increasing Drug Use Among Individuals with Parkinson Disease Before and After a Serious Injury (P2-5.032)

<h3>Objective:</h3> To describe fall risk-increasing drug (FRID) use before and after an unintentional traumatic injury or fall-related fracture and examine the extent to which hospital encounters affect medication prescribing in individuals with Parkinson disease (PD). <h3>Background:</h3> Individuals with PD are at increased risk of falls and fractures. FRIDs represent a major modifiable factor that can potentially reduce the risk of subsequent events. <h3>Design/Methods:</h3> We identified persons with PD hospitalized for injury or fracture and matched each person to up to 4 individuals with PD who were hospitalized for other reasons using 2013–2017 U.S. Medicare data. A difference-in-difference design was used to compare FRID dispensing before and after hospitalization between the two groups. We examined the changes in standardized daily doses of FRIDs in the two groups upon hospital admission and at 3-, 6-, and 12-months post-discharge, adjusting for covariates. Exploratory analyses were performed to evaluate potential medication discontinuation and tapering following discharge. <h3>Results:</h3> We identified 9,437 persons with PD who had a qualifying hospitalization for injury or fracture and 32,487 matched individuals. While both groups experienced reductions in standardized daily doses of FRIDs, the differences in dose reductions were minimal (−1.94, 95% CI [−2.05, −1.82] in the injury group vs. −1.91, 95% CI [−1.97, −1.84] in the non-injury group; p=0.66 at 12 months). Over 40% of subjects discontinued FRIDs at 3 months in both groups, and ~2/3 to 3/4 of these sustained discontinuations through one year. <h3>Conclusions:</h3> There were no clinically significant differences in FRID dose reductions pre- to post-hospitalization between PD individuals with injury or fracture versus those without. More efforts are needed to enhance deprescribing practices during transition of care, especially after a sentinel event, to prevent subsequent unintentional injuries or fractures. <b>Disclosure:</b> The institution of Dr. Pham Nguyen has received research support from National Institute of Health. The institution of Dr. Pham Nguyen has received research support from National Institute of Health. Dr. Gray has nothing to disclose. Mr. Newcomb has nothing to disclose. Miss Liu has nothing to disclose. The institution of Dr. Hamedani has received research support from Michael J. Fox Foundation. The institution of Dr. Hamedani has received research support from NIH. The institution of Dr. Hamedani has received research support from Biogen. The institution of Dr. Hamedani has received research support from Biohaven. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Biogen. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Intercept Pharmaceuticals. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Medullary Thyroid Cancer Consortium. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Provention Bio, Inc. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Bluebird bio, Inc. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Amylyx Pharmaceuticals. Dr. Hennessy has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ipsen Bioscence Inc.. The institution of Dr. Hennessy has received research support from US Food and Drug Administration. The institution of Dr. Hennessy has received research support from US National Institutes of Health. The institution of Dr. Hennessy has received research support from US Centers for Disease Control and Prevention. Dr. Wright Willis has received personal compensation in the range of $0-$499 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Pharmacoepidemiology and Drug Safety. The institution of Dr. Wright Willis has received research support from NIH. The institution of Dr. Wright Willis has received research support from NIA. The institution of Dr. Wright Willis has received research support from Biogen. The institution of Dr. Wright Willis has received research support from Parkinson Foundation. The institution of Dr. Wright Willis has received research support from Arcadia.

Antidepressant drug-drug-drug interactions associated with unintentional traumatic injury: Screening for signals in real-world data.

Antidepressants are associated with traumatic injury and are widely used with other medications. It remains unknown how drug-drug-drug interactions (3DIs) between antidepressants and two other drugs may impact potential injury risks associated with antidepressants. We aimed to generate hypotheses regarding antidepressant 3DI signals associated with elevated injury rates. Using 2000-2020 Optum's de-identified Clinformatics Data Mart, we performed a self-controlled case series study for each drug triad consisting of an antidepressant + codispensed drug (base-pair) with a candidate interacting medication (precipitant). We included persons aged greater than or equal to 16 years who (1) experienced an injury and (2) used a candidate precipitant, during base-pair therapy. We compared injury rates during observation time exposed to the drug triad versus the base-pair only, adjusting for time-varying covariates. We calculated adjusted rate ratios (RRs) using conditional Poisson regression and accounted for multiple comparisons via semi-Bayes shrinkage. Among 147,747 eligible antidepressant users with an injury, we studied 120,714 antidepressant triads, of which 334 (0.3%) were positively associated with elevated injury rates and thus considered potential 3DI signals. Adjusted RRs for signals ranged from 1.31 (1.04-1.65) for sertraline + levothyroxine with tramadol (vs. without tramadol) to 6.60 (3.23-13.46) for escitalopram + simvastatin with aripiprazole (vs. without aripiprazole). Nearly half of the signals (137, 41.0%) had adjusted RRs greater than or equal to 2, suggesting strong associations with injury. The identified signals may represent antidepressant 3DIs of potential clinical concern and warrant future etiologic studies to test these hypotheses.

Population-based screening to detect benzodiazepine drug-drug-drug interaction signals associated with unintentional traumatic injury

Drug interactions involving benzodiazepines and related drugs (BZDs) are increasingly recognized as a contributor to increased risk of unintentional traumatic injury. Yet, it remains unknown to what extent drug interaction triads (3DIs) may amplify BZDs’ inherent injury risk. We identified BZD 3DI signals associated with increased injury rates by conducting high-throughput pharmacoepidemiologic screening of 2000–2019 Optum’s health insurance data. Using self-controlled case series design, we included patients aged ≥ 16 years with an injury while using a BZD + co-dispensed medication (i.e., base pair). During base pair-exposed observation time, we identified other co-dispensed medications as candidate interacting precipitants. Within each patient, we compared injury rates during time exposed to the drug triad versus to the base pair only using conditional Poisson regression, adjusting for time-varying covariates. We calculated rate ratios (RRs) with 95% confidence intervals (CIs) and accounted for multiple estimation via semi-Bayes shrinkage. Among the 65,123 BZD triads examined, 79 (0.1%) were associated with increased injury rates and considered 3DI signals. Adjusted RRs for signals ranged from 3.01 (95% CI = 1.53–5.94) for clonazepam + atorvastatin with cefuroxime to 1.42 (95% CI = 1.00–2.02, p = 0.049) for alprazolam + hydrocodone with tizanidine. These signals may help researchers prioritize future etiologic studies to investigate higher-order BZD interactions.

Skeletal muscle relaxant drug-drug-drug interactions and unintentional traumatic injury: Screening to detect three-way drug interaction signals.

The aim of this study was to identify skeletal muscle relaxant (SMR) drug-drug-drug interaction (3DI) signals associated with increased rates of unintentional traumatic injury. We conducted automated high-throughput pharmacoepidemiologic screening of 2000-2019 healthcare data for members of United States commercial and Medicare Advantage health plans. We performed a self-controlled case series study for each drug triad consisting of an SMR base-pair (i.e., concomitant use of an SMR with another medication), and a co-dispensed medication (i.e., candidate interacting precipitant) taken during ongoing use of the base-pair. We included patients aged ≥16 years with an injury occurring during base-pair-exposed observation time. We used conditional Poisson regression to calculate adjusted rate ratios (RRs) with 95% confidence intervals (CIs) for injury with each SMR base-pair + candidate interacting precipitant (i.e., triad) versus the SMR-containing base-pair alone. Among 58 478 triads, 29 were significantly positively associated with injury; confounder-adjusted RRs ranged from 1.39 (95% CI = 1.01-1.91) for tizanidine + omeprazole with gabapentin to 2.23 (95% CI = 1.02-4.87) for tizanidine + diclofenac with alprazolam. Most identified 3DI signals are new and have not been formally investigated. We identified 29 SMR 3DI signals associated with increased rates of injury. Future aetiologic studies should confirm or refute these SMR 3DI signals.

Opioid Drug-Drug-Drug Interactions and Unintentional Traumatic Injury: Screening to Detect Three-Way Drug Interaction Signals.

Growing evidence suggests that drug interactions may be responsible for much of the known association between opioid use and unintentional traumatic injury. While prior research has focused on pairwise drug interactions, the role of higher-order (i.e., drug-drug-drug) interactions (3DIs) has not been examined. We aimed to identify signals of opioid 3DIs with commonly co-dispensed medications leading to unintentional traumatic injury, using semi-automated high-throughput screening of US commercial health insurance data. We conducted bi-directional, self-controlled case series studies using 2000–2015 Optum Data Mart database. Rates of unintentional traumatic injury were examined in individuals dispensed opioid-precipitant base pairs during time exposed vs unexposed to a candidate interacting precipitant. Underlying cohorts consisted of 16–90-year-olds with new use of opioid-precipitant base pairs and ≥1 injury during observation periods. We used conditional Poisson regression to estimate rate ratios adjusted for time-varying confounders, and semi-Bayes shrinkage to address multiple estimation. For hydrocodone, tramadol, and oxycodone (the most commonly used opioids), we examined 16,024, 8185, and 9330 drug triplets, respectively. Among these, 75 (0.5%; hydrocodone), 57 (0.7%; tramadol), and 42 (0.5%; oxycodone) were significantly positively associated with unintentional traumatic injury (50 unique base precipitants, 34 unique candidate precipitants) and therefore deemed potential 3DI signals. The signals found in this study provide valuable foundations for future research into opioid 3DIs, generating hypotheses to motivate crucially needed etiologic investigations. Further, this study applies a novel approach for 3DI signal detection using pharmacoepidemiologic screening of health insurance data, which could have broad applicability across drug classes and databases.

Population-based signals of benzodiazepine drug interactions associated with unintentional traumatic injury

Benzodiazepine receptor agonists and related medications, such as Z-drugs and dual orexin receptor antagonists (BZDs), have been associated with unintentional traumatic injury due to their central nervous system (CNS)-depressant effects. Drug-drug interactions (DDIs) may contribute to the known relationship between BZD use and unintentional traumatic injury, yet evidence is still lacking. We conducted high-throughput pharmacoepidemiologic screening using the self-controlled case series design in a large US commercial health insurance database to identify potentially clinically relevant DDI signals among new users of BZDs. We used conditional Poisson regression to estimate rate ratios (RRs) between each co-exposure (vs. not) and unintentional traumatic injury (primary outcome), typical hip fracture (secondary outcome), and motor vehicle crash (secondary outcome). We identified 48 potential DDI signals (1.1%, involving 39 unique co-dispensed drugs), i.e., with statistically significant elevated adjusted RRs for injury. Signals were strongest for DDI pairs involving zolpidem, lorazepam, temazepam, alprazolam, eszopiclone, triazolam, and clonazepam. We also identified four potential DDI signals for typical hip fracture, but none for motor vehicle crash. Many signals have biologically plausible explanations through additive or synergistic pharmacodynamic effects of co-dispensed antidepressants, opioids, or muscle relaxants on CNS depression, impaired psychomotor and cognitive function, and/or somnolence. While other signals that lack an obvious mechanism may represent true associations that place patients at risk of injury, it is also prudent to consider the roles of chance, reverse causation, and/or confounding by indication, which merit further exploration. Given the high-throughput nature of our investigation, findings should be interpreted as hypothesis generating.

Signals of Muscle Relaxant Drug Interactions Associated with Unintentional Traumatic Injury: A Population-Based Screening Study.

Use of muscle relaxants is rapidly increasing in the USA. Little is understood about the role of drug interactions in the known association between muscle relaxants and unintentional traumatic injury, a clinically important endpoint causing substantial morbidity, disability, and death. We examined potential associations between concomitant drugs (i.e., precipitants) taken with muscle relaxants (affected drugs, i.e., objects) and hospital presentation for unintentional traumatic injury. In a series of self-controlled case series studies, we screened to identify drug interaction signals for muscle relaxant + precipitant pairs and unintentional traumatic injury. We used Optum's de-identified Clinformatics® Data Mart Database, 2000-2019. We included new users of a muscle relaxant, aged 16-90years, who were dispensed at least one precipitant drug and experienced an unintentional traumatic injury during the observation period. We classified each observation day as precipitant exposed or precipitant unexposed. The outcome was an emergency department or inpatient discharge diagnosis for unintentional traumatic injury. We used conditional Poisson regression to estimate rate ratios adjusting for time-varying confounders and then accounted for multiple estimation via semi-Bayes shrinkage. We identified 74,657 people who initiated muscle relaxants and experienced an unintentional traumatic injury, in whom we studied concomitant use of 2543 muscle relaxant + precipitant pairs. After adjusting for time-varying confounders, 16 (0.6%) pairs were statistically significantly and positively associated with injury, and therefore deemed signals of a potential drug interaction. Among signals, semi-Bayes shrunk, confounder-adjusted rate ratios ranged from 1.29 (95% confidence interval 1.04-1.62) for baclofen + sertraline to 2.28 (95% confidence interval 1.14-4.55) for methocarbamol + lamotrigine. Using real-world data, we identified several new signals of potential muscle relaxant drug interactions associated with unintentional traumatic injury. Only one among 16 signals is currently reported in a major drug interaction knowledge base. Future studies should seek to confirm or refute these signals.

Victims of Violence and Post-Discharge Adverse Events: A Prospective Modified Trauma Quality Improvement Program (TQIP) Study.

IntroductionTrauma patients frequently return to an emergency department (ED) soon after discharge; often for non-urgent reasons. Social factors contribute to higher ED usage. At present, there is no standardized system for reporting of ED visits and readmissions among trauma care. We hypothesized that victims of violent crime suffer from many early post-discharge adverse events that has not been captured by current methods.MethodsWe prospectively consented and enrolled injured patients from January 1st, 2019 to December 31st, 2019. We documented 30-day post-discharge events using post-discharge phone calls and detailed chart abstraction. Patients were categorized as victims of violence (VV) or unintentional traumatic injury (UT).ResultsDuring the study period, 444 patients were enrolled. Fifty-one (11.5%) were victims of violence and 393 (88.5%) experienced unintentional injuries. The VV patients were younger (40.10 vs 60.36; p<0.0001), and more predominantly male (92.16% vs 57.51%; p<0.0001). Total injury severity score (ISS), critical care length of stay (LOS), and total LOS were similar. VV patients were more likely discharged home (70.59% vs 55.47%; p=0.0403). They were significantly more likely to return to an emergency department (47.06% vs 23.16%; p<0.0005) and had more total number of ED visits per patient. Readmission rates, however, were not different (21.57% vs 16.28%; p=NS). The VV patients more frequently were underinsured (72.5%, vs 20.6%, p<0.005).DiscussionVictims of violence presented to the ED significantly more often, despite similar injury scores, LOS, and being of younger age. Of these patients, only 26.2% of ED presentations resulted in readmission, suggesting the majority of patient complaints may have been able to be managed in an office-based setting. VV had significantly more underinsured or subsidized patients. Victims of violence are vulnerable and may benefit from more resources provided in the early post-discharge period.

Population-Based Signals of Antidepressant Drug Interactions Associated With Unintentional Traumatic Injury.

Antidepressants are very widely used and associated with traumatic injury, yet little is known about their potential for harmful drug interactions. We aimed to identify potential drug interaction signals by assessing concomitant medications (precipitant drugs) taken with individual antidepressants (object drugs) that were associated with unintentional traumatic injury. We conducted pharmacoepidemiologic screening of 2000-2015 Optum Clinformatics data, identifying drug interaction signals by performing self-controlled case series studies for antidepressant+precipitant pairs and injury. We included persons aged 16-90years codispensed an antidepressant and ≥1 precipitant drug(s), with an injury during antidepressant therapy. We classified antidepressant person-days as either precipitant-exposed or precipitant-unexposed. The outcome was an emergency department or inpatient discharge diagnosis for unintentional traumatic injury. We used conditional Poisson regression to calculate confounder adjusted rate ratios (RRs) and accounted for multiple estimation via semi-Bayes shrinkage. We identified 330,884 new users of antidepressants who experienced an injury. Among such persons, we studied concomitant use of 7,953 antidepressant+precipitant pairs. Two hundred fifty-six (3.2%) pairs were positively associated with injury and deemed potential drug interaction signals; 22 of these signals had adjusted RRs>2.00. Adjusted RRs ranged from 1.06 (95% confidence interval: 1.00-1.12, P=0.04) for citalopram+gabapentin to 3.06 (1.42-6.60) for nefazodone+levonorgestrel. Sixty-five (25.4%) signals are currently reported in a seminal drug interaction knowledgebase. We identified numerous new population-based signals of antidepressant drug interactions associated with unintentional traumatic injury. Future studies, intended to test hypotheses, should confirm or refute these potential interactions.

Excellence in Communication and Emergency Leadership (ExCEL): Pediatric Primary and Secondary Survey in Trauma Workshop for Residents.

IntroductionUnintentional traumatic injury remains the leading cause of pediatric death in the United States. There is wide variation in the assessment and management of pediatric trauma patients in emergency departments. Resident education on trauma evaluation and management is lacking. This workshop focused on developing resident familiarity with the primary and secondary trauma survey in pediatric patients.MethodsThis hands-on workshop utilized patient-actors and low-fidelity simulators to instruct learners on the initial assessment of trauma patients during the primary and secondary trauma surveys. It was designed for residents across all levels of training who care for pediatric trauma patients (including pediatrics, medicine-pediatrics, emergency medicine, and family medicine) and adapted for different session durations and learner group sizes.ResultsEighteen residents participated in this workshop at two separate institutions. Participants strongly agreed that the workshop was relevant and effective in teaching the initial primary and secondary trauma survey assessment of pediatric trauma patients. Residents also reported high levels of confidence in performing a primary and secondary trauma survey after participation in the workshop.DiscussionThis workshop provided residents with instruction and practice in performing the primary and secondary trauma survey for injured pediatric patients. Additional instruction is needed on assigning Glasgow Coma Scale and AVPU (alert, voice, pain, unresponsive) scores to injured patients. The structure and time line of this curriculum can be adapted to the needs of an individual institution's program and the number of workshop participants.

Screening to identify signals of opioid drug interactions leading to unintentional traumatic injury

BackgroundEfforts to minimize harms from opioid drug interactions may be hampered by limited evidence on which drugs, when taken concomitantly with opioids, result in adverse clinical outcomes. ObjectiveTo identify signals of opioid drug interactions by identifying concomitant medications (precipitant drugs) taken with individual opioids (object drugs) that are associated with unintentional traumatic injury DesignWe conducted pharmacoepidemiologic screening of Optum Clinformatics Data Mart, identifying drug interaction signals by performing confounder-adjusted self-controlled case series studies for opioid + precipitant pairs and injury. SettingBeneficiaries of a major United States-based commercial health insurer during 2000–2015 PatientsPersons aged 16–90 years co-dispensed an opioid and ≥1 precipitant drug(s), with an unintentional traumatic injury event during opioid therapy, as dictated by the case-only design ExposurePrecipitant-exposed (vs. precipitant-unexposed) person-days during opioid therapy. Outcome: Emergency department or inpatient International Classification of Diseases discharge diagnosis for unintentional traumatic injury. We used conditional Poisson regression to generate confounder adjusted rate ratios. We accounted for multiple estimation via semi-Bayes shrinkage. ResultsWe identified 25,019, 12,650, and 10,826 new users of hydrocodone, tramadol, and oxycodone who experienced an unintentional traumatic injury. Among 464, 376, and 389 hydrocodone-, tramadol-, and oxycodone-precipitant pairs examined, 20, 17, and 16 (i.e., 53 pairs, 34 unique precipitants) were positively associated with unintentional traumatic injury and deemed potential drug interaction signals. Adjusted rate ratios ranged from 1.23 (95 % confidence interval: 1.05–1.44) for hydrocodone + amoxicillin-clavulanate to 4.21 (1.88–9.42) for oxycodone + telmisartan. Twenty (37.7 %) of 53 signals are currently reported in a major drug interaction knowledgebase. LimitationsPotential for reverse causation, confounding by indication, and chance ConclusionsWe identified previously undescribed and/or unappreciated signals of opioid drug interactions associated with unintentional traumatic injury. Subsequent etiologic studies should confirm (or refute) and elucidate these potential drug interactions.

Generalized Subcutaneous Emphysema Secondary to Pneumomediastinum in a Newborn kitten

Background: Pneumomediastinum is a rare entity characterized by the introduction of air into the mediastinum. Primary or spontaneous pneumomediastinum may occur in the absence of any disease whereas secondary pneumomediastinum may be due to a number of precipitating factors. The clinical picture is severe and the onset is acute. The present report describes the clinical presentation, treatment, and the findings of a forensic investigation of a case of generalized subcutaneous emphysema secundary to pneumomediastinum in a newborn kitten. Case: A newborn kitten was presented to a veterinary climic with a history of generalized air accumulation in the subcutaneous tissue of acute onset which was noted whenever the animal suckled. Clinical care and radiographic examination were performed. Radiographic findings included areas of radiolucency within the subcutis suggestive of generalized subcutaneous emphysema. In the thoracic cavity, there was ventral displacement of the thoracic trachea and increased radiolucency in the cranial mediastinum suggestive of pneumomediastinum. There was loss of definition of the cervical trachea suggestive of tracheal rupture. Based on the radiographic findings, the clinician decided to aspirate the air accumated within the subcutis using a needle and a syringe. However, this emphysema rapidly formed after the subcutaneous air was aspirated. Euthanasia was elected due to the poor prognosis and the animal was submitted for necropsy. Main gross findings included traumatic intercostal laceration adjacent to the lungs under the axilla and tracheal perforation. Tracheal perforation resulted in persistent air leakage from the trachea causing pneumomediastinum which evolved into generalized subcutaneous emphysema causing the animal to inflate as air became trapped within the subcutis imparting a blown up appearance to the cat. Microscopically pulmonary collapse was observed. Symptomatic treatment was instituted and consisted of puncturing the distended skin with needle and syringe. Percutaneous drainage of the subcutaneous air was unsuccessful.Discussion: In the present case, the diagnosis of generalized subcutaneous emphysema due to pneumomediastinum in a newborn kitten was based on the history, clinical signs, radiographic findings, and gross necropsy lesions. However, the histopathological findings were non-specific. The present case is an example of secondary pneumomediastinum. Tracheal perforation resulted in massive air penetration into the mediastinum. Generalized subcutaneous emphysema developed as a complication of the pneumomediastinum. Queens carry their offspring using their mouth. We suggest that the tracheal lesion is a penetrating tracheal trauma and that this injury was inflicted by the mother's canine teeth as she transported the kitten with the animal's neck and chest inside her mouth. There was no history that the kitten was attacked by other animal or of any other type of trauma. Initial conservative treatment consisted of puncturing the skin in order to release subcutaneous air and relieve pain. Oxygen supply was not considered due to practical reasons since such supportive therapy would worsen the clinical picture of the patient. Necropsy findings were of major importance to establish a definitive diagnosis. Gross lesions included tracheal perforation, which caused pneumomediastinum through air leakage into the mediastinum and lead to the subcutaneous emphysema. We conclude that unintentional traumatic injuries in a newborn kitten caused by the queen should be considered as a cause of pneumomediastinum and subcutaneous emphysema. The clinical picture is severe, of acute onset, and exhibits a rapidly progressive course.

Research on Injury Disparities: A Scoping Review.

Background: Research on disparities in traumatic injury has not been well characterized, limiting understanding of gaps in research and development of successful interventions. We conducted a scoping review to identify and synthesize research on disparities in intentional and unintentional traumatic injuries.Methods: The review was guided by PRISMA Extension for Scoping Reviews. PubMed, PsycINFO, Web of Science, and CINAHL and systematic reviews from 2007 to 2017 were searched. Eligible articles were peer reviewed; conducted in the United States; and reported on clearly defined physical trauma and disparity, defined by Cochrane PROGRESS-Plus criteria. One reviewer assessed article titles and a second reviewer validated the inclusion with a random sample. and full-text review by two reviewers determined final inclusion.Results: Of 7382 unique articles screened, 653 articles were included; inter-rater agreement was high (K=0.995). Studies reported on disparities in the acute hospital setting (104) or postacute/rehabilitation (86), with fewer focused on prevention (57) and policy development (6). Research methods used were quantitative (593) with 25 intervention studies, qualitative (45), qualitative/quantitative (7), and community-based participatory research (8). Age ranges of included studies were all ages (124), adults (318), pediatric/youth/adolescents (172), and older adults (40). Racial disparities were most commonly measured (439 studies); 38 created a white/nonwhite binary. Other commonly measured disparities were place of residence (122), insurance (111 studies), gender (89), age (75), and socioeconomic status measures (61). Disparities were noted in all of the categories. Studies commonly aggregated all types of traumatic injuries (129) or all types of violence (105).Conclusions: The extant injury literature lacks research on prevention and policy to address disparities. Many studies aggregated types of trauma and patient groups, preventing an understanding of distinctions between groups and potential interventions. Intervention and community-based research strategies were limited. Future research can better specify measurement of understudied equity categories, trauma types and intent, and racial groups.

Risks Go Beyond the Violence: Association Between Intimate Partner Violence, Mental Illness, and Substance Abuse Among Females Admitted to a Rural Level I Trauma Center: Hink AB, Toschlog E, Waibel B, et al. J Trauma Acute Care Surg. 2015;79:709-716

Intimate partner violence (IPV) has previously been demonstrated to be associated with mental illness, suicidality, and alcohol and substance abuse. These factors are common in the trauma setting, and have been independently shown to be associated with both intentional and unintentional traumatic injury. However, there have thus far been few studies describing the relationship between these risk factors for IPV and IPV itself in trauma populations.

Contextual Determinants of Childhood Injury: A Systematic Review of Studies With Multilevel Analytic Methods

Background. The definition of injury that underpins the contemporary approach to injury prevention is an etiological definition relating to bodily damage arising from transfer of energy to tissues of the body beyond the limits compatible with physiological function. Causal factors proximal to the energy transfer are nested within a more complex set of contextual determinants. For effective injury control, understanding of these determinants is critical. Objectives. The primary aims of this study were to describe the area-level determinants that have been included in multilevel analyses of childhood injury and to quantify the relationships between these area-level exposures and injury outcomes. Search methods. We conducted a systematic review of peer-reviewed, English-language literature published in scientific journals between January 1997 and July 2014, reporting studies that employed multilevel analyses to quantify the eco-epidemiological causation of physical unintentional injuries to children aged 16 years and younger. We conducted and reported the review in accordance with the PRISMA guidelines. Selection criteria. We included etiological studies of causal risk factors for unintentional traumatic injuries to children aged 0 to 16 years. Methodological inclusion criteria were as follows: Epidemiological studies quantifying the relationship between risk factors (at various levels) and injury occurrence in the individual; Studies that recognized individual exposure and at least 1 higher level of exposure with units at lower levels or microunits (e.g., individuals) nested within units at higher levels or macrounits (e.g., areas or neighborhoods); Injury outcomes (dependent variable) examined at the individual level; and Central analytic techniques belonging to the following categories: multilevel models, hierarchical models, random effects models, random coefficient models, covariance components models, variance components models, and mixed models. We combined criteria from the checklist described by the Cochrane Effective Practice and Organization of Care Review Group with factors in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement, and we used several quality assessment items from other injury-related systematic reviews to create a quality assessment checklist for this review. Data collection and analysis. Two authors independently extracted data and selected analysis features for the included studies by using preformatted tables. They extracted information as reported in the articles. We determined statistical significance of estimates and effects by using the conventional threshold, P &lt; .05. Any differences in the information extracted were resolved by discussion between authors and by specifically rereading and rechecking the facts as reported in the relevant articles. We tabulated results from the final multilevel model(s) in each of the included articles with key aspects summarized in text. Interpretations of the results and identification of key issues raised by the collated material are reported in the Discussion section of this article. Main results. We identified 11 967 articles from the electronic search with only 14 being included in the review after a detailed screening and selection process. Nine of the 14 studies identified significant fixed effects at both the area and individual levels. The area-level variables most consistently associated with child injury rates related to poverty, education, employment, and access to services. There was some evidence that injury rates were lower in areas scoring well on area-level summary measures of neighborhood safety. There was marked variation in the methods used and in the mapping of measured variables onto the conceptual model of ecological causation. Author conclusions. These results help establish the scope for the public policy approach to injury prevention. More consistent reporting of multilevel study results would aid future interpretation and translation of such findings.

Contextual Determinants of Childhood Injury: A Systematic Review of Studies With Multilevel Analytic Methods.

The definition of injury that underpins the contemporary approach to injury prevention is an etiological definition relating to bodily damage arising from transfer of energy to tissues of the body beyond the limits compatible with physiological function. Causal factors proximal to the energy transfer are nested within a more complex set of contextual determinants. For effective injury control, understanding of these determinants is critical. The primary aims of this study were to describe the area-level determinants that have been included in multilevel analyses of childhood injury and to quantify the relationships between these area-level exposures and injury outcomes. We conducted a systematic review of peer-reviewed, English-language literature published in scientific journals between January 1997 and July 2014, reporting studies that employed multilevel analyses to quantify the eco-epidemiological causation of physical unintentional injuries to children aged 16 years and younger. We conducted and reported the review in accordance with the PRISMA guidelines. We included etiological studies of causal risk factors for unintentional traumatic injuries to children aged 0 to 16 years. Methodological inclusion criteria were as follows: Epidemiological studies quantifying the relationship between risk factors (at various levels) and injury occurrence in the individual; Studies that recognized individual exposure and at least 1 higher level of exposure with units at lower levels or microunits (e.g., individuals) nested within units at higher levels or macrounits (e.g., areas or neighborhoods); Injury outcomes (dependent variable) examined at the individual level; and Central analytic techniques belonging to the following categories: multilevel models, hierarchical models, random effects models, random coefficient models, covariance components models, variance components models, and mixed models. We combined criteria from the checklist described by the Cochrane Effective Practice and Organization of Care Review Group with factors in the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement, and we used several quality assessment items from other injury-related systematic reviews to create a quality assessment checklist for this review. Two authors independently extracted data and selected analysis features for the included studies by using preformatted tables. They extracted information as reported in the articles. We determined statistical significance of estimates and effects by using the conventional threshold, P < .05. Any differences in the information extracted were resolved by discussion between authors and by specifically rereading and rechecking the facts as reported in the relevant articles. We tabulated results from the final multilevel model(s) in each of the included articles with key aspects summarized in text. Interpretations of the results and identification of key issues raised by the collated material are reported in the Discussion section of this article. We identified 11,967 articles from the electronic search with only 14 being included in the review after a detailed screening and selection process. Nine of the 14 studies identified significant fixed effects at both the area and individual levels. The area-level variables most consistently associated with child injury rates related to poverty, education, employment, and access to services. There was some evidence that injury rates were lower in areas scoring well on area-level summary measures of neighborhood safety. There was marked variation in the methods used and in the mapping of measured variables onto the conceptual model of ecological causation. AUTHOR CONCLUSIONS: These results help establish the scope for the public policy approach to injury prevention. More consistent reporting of multilevel study results would aid future interpretation and translation of such findings.

The risk of pediatric bicycle handlebar injury compared with non-handlebar injury: a retrospective multicenter study in Osaka, Japan.

BackgroundBicycle accidents are one of the major causes of unintentional traumatic injury in childhood. The purpose of this study was to examine characteristics and risks of handlebar injury in childhood.MethodsWe conducted a more than 5-year retrospective survey of patients under 15 years of age with bicycle-related injuries admitted to eight urban tertiary emergency centers in Osaka, Japan. Patients were divided into the direct-impact handlebar injury (HI) group and the non-handlebar injury (NHI) group.ResultsThe HI group included 18 patients and the NHI group included 308 patients. Median Injury Severity Score (ISS) in the HI group was 9. Injury sites included the chest, 2 (chest bruise, 1; tracheal injury, 1) and abdomen, 16 (hepatic injury, 6; pancreatic injury, 2; duodenal injury, 1; splenic injury, 1; small intestinal injury, 1; retroperitoneal hemorrhage, 1; renal injury, 1; abdominal wall musculature injury, 2; bladder injury, 1; and perineal laceration, 1). There were no significant differences in age, sex, ISS, and prognosis between the two groups. However, significant differences were seen in the abdominal median Abbreviated Injury Scale (AIS) score, which was higher in the HI group (3 vs 0, p < 0.01), and in the head median AIS score, which was higher in the NHI group (0 vs 2, p < 0.01). As mechanisms of injury, falling while riding a bicycle occurred significantly more frequently in the HI group (17 [94.4 %] vs 65 [21.1 %], p < 0.01). Direct transportation from the scene of the accident occurred significantly more often in the NHI group (5 [27.8 %] vs 255 [82.8 %], p < 0.01), whereas transfer from another hospital occurred significantly more frequently in the HI group (11 [61.1 %] vs 45 [14.6 %], p < 0.01).ConclusionsHandlebar injuries in children have significant potential to cause severe damage to visceral organs, especially those in the abdomen.

Recovery from traumatic injury: Trauma patients’ perceptions of facilitators and barriers

BackgroundIndividuals who have sustained an unintentional physical traumatic injury often undergo a lengthy and arduous process of recovery, as they strive to return to pre-injury levels of physical, occupational and social function. However, little research has been conducted on interventions to support trauma patients during recovery, and the few interventions implemented have limited success. ObjectivesThis qualitative descriptive study was designed to explore the facilitators and barriers to the recovery process to inform nursing interventions and research. MethodsA sample of 13 individuals in the southeast United States, who sustained an unintentional traumatic injury requiring hospitalization in the previous 6months, completed an in-person semi-structured interview. Data were analyzed using line by line coding, identification of patterns and themes, and constant comparison of themes to the data. ResultsFour major themes that facilitated recovery from injury were identified: support, coping, processing, and progress. Major barriers to recovery included financial losses, physical changes, lack of information, and emotional consequences. DiscussionTrauma patients need informational and support resources, especially peer support from those with a similar injury, to provide indicators of progress and promote successful integration of the injury event and its consequences into their views of self.

More Than Bike Helmets and Car Seats

More Than Bike Helmets and Car Seats

Family functioning and posttraumatic stress symptoms in youth and their parents after unintentional pediatric injury

This study examined the association between family functioning and the development of posttraumatic stress symptoms (PTSS) in youth and parents following an unintentional traumatic injury of a child. Fifty-one parent-child dyads completed questionnaires and a structured interview assessing PTSS and family functioning. Multiple regression analyses were applied to evaluate the contribution of family functioning to the development of PTSS after controlling for demographic characteristics and known predictors. Family functioning had both direct and moderating influences on the development of PTSS in parents. We were unable to demonstrate a systematic impact of family functioning on the development of PTSS in children from the same families.