Cervical spine evaluation is a critical component in trauma evaluation, and though several pediatric cervical spine evaluation algorithms have been developed, none has been widely implemented. Here, ...we assess rates of cervical spine imaging use across children's hospitals, specifically temporal trends in imaging use, variation across hospitals in imaging used, and timing of magnetic resonance imaging in admitted patients.
Data from the Children's Hospital Associations Pediatric Health Information System was abstracted from 2015 to 2020. Patients less than 18 years of age seen in the emergency department with an International Classification of Diseases (ICD)-10 code indicative of trauma and cervical spine plain radiograph or computed tomography in the emergency department were included. Data visualization and descriptive statistics were used to assess rates of imaging use by age, year, hospital, injury severity, and day of service. Changes in rates of imaging use over time were evaluated via Chi-square test.
Across 25,238 patient encounters at 35 children's hospitals, there was an increase in use of cervical spine computed tomography from 2015 to 2020 (28.5 to 36.5%). There was substantial inter-institutional variation in rates of use of plain radiographs versus computed tomography for initial evaluation of the cervical spine across all age groups and regardless of rates of severe injury across institutions. Magnetic resonance imaging was obtained more than three days after admission in 31.5% of intensive care patients who received this imaging.
Increasing use of computed tomography, substantial inter-institutional variation in rates of use of plain radiographs versus computed tomography, and heterogenous timing of magnetic resonance imaging for evaluation of the pediatric cervical spine demonstrate the growing need for development and implementation of an age-specific cervical spine evaluation algorithm to guide judicious use of diagnostic resources.
Level III, Epidemiologic.
Unhoused patients are an overrepresented group in burn injury, and are a uniquely vulnerable population. Current research focuses on the consequences of homelessness on burn outcomes, with little ...known about the specific circumstances and behaviors leading to burn injury that may represent specific targets for injury prevention efforts. The burn registry at an urban regional burn center was queried for burn admissions in unhoused adults from 2019 to 2022. Registry data pulled included demographics, urine toxicology, mechanism of injury, and injury subjective history. Subjective injury history was reviewed to determine more specific injury circumstances and activities during which accidental burns occurred. Demographic and mechanistic trends in burn admissions were explored via descriptive statistics. Among 254 admissions for burns from the unhoused community, 58.1% of patients were positive for stimulants on admission. Among accidental injuries (69.7%), common circumstances included preparing food or beverages, cooking or using methamphetamine, smoking cannabis or tobacco, bonfires, and candles. A specific common circumstance was lighting a cigarette while handling accelerants (6.7%). Interventions for stimulant abuse, as well as outreach efforts to educate unhoused patients about situational awareness, safe handling of accelerants, safe smoking practices, and safe cooking practices, may be effective tools in reducing burn admissions in this vulnerable population.
Previous research has demonstrated mixed relationships between individual neighborhood socioeconomic factors and incidences of violence, such as poverty level, population density, and income ...inequality. We used the Childhood Opportunity Index and Area Disadvantage Index to evaluate the relationship between neighborhood characteristics and the number of incidents of violence among children across the zip codes of Los Angeles (LA) County.
We performed a retrospective cross-sectional study of children aged <18 years from 2017-2019 who were entered in the LA County Trauma and Emergency Medicine Information System registry with violent mechanisms of injury, including gunshot, stabbing, or assault. Mechanisms classified as self-inflicted injuries were excluded from the study. The number of incidences of violent mechanism per 100,000 persons under 18 years for each zip code were calculated using population data from the US Census American Community Survey 5-Year estimates from 2019.The incidences of violence per capita under 18 years for each zip code was compared to the zip code Area Deprivation Index and Childhood Opportunity using logistic regression models.
There were 6,791 trauma activations in LA County over the study period, 12.8% (n = 866) of which were due to violence. The mean prevalence of pediatric violent mechanism of injury per zip code was 4 cases per 100,000 persons under 18 years. Most injuries were the result of firearms (n = 345, 60.4%) and occurred among Hispanic/Latino children (n = 362, 57.1%). There were significantly greater rates of violent injury among children from highest disadvantage (OR = 8.84) and lowest opportunity (OR 42.48) zip codes.
Children living in high disadvantage or low opportunity zip codes had greater rates of violent injury. Further study of neighborhood factors is needed to develop targeted, effective interventions to reduce violent injuries among children living in low opportunity areas.
Level III, Epidemiological.
Abstract Nutrition is paramount for wound healing after burn injury. With rising food prices and time off work due to burn injuries, access to adequate nutrition may be a significant financial ...stressor. We asked patients at an outpatient burn clinic to complete the Household Food Security Module, which queries about food security over the preceding 12 months. Demographics and burn characteristics were abstracted from the medical record. We assessed the overall prevalence of food insecurity, risk factors for food insecurity, and potential effects of food insecurity on nutritional status and wound healing time. Wound healing time was assessed via Cox regression while adjusting for burn depth, total body surface area burned, and diabetes. Over 40% of participants reported experiencing food insecurity; it was more common in patients who preferred Spanish language (P = 0014) or were unemployed (P = .049). Just over half of participants experiencing food insecurity were using any food assistance resources. Among patients more than 30 days from burn injury, patients who were food insecure had larger burns (P = .01). Experience of food insecurity was not associated presence of malnutrition on nutrition-focused physical exam (P = .47). Wound healing time for burns managed in the outpatient setting was associated with burn depth (P < .001), but not food insecurity (P = .95), burn size (P = .17), or diabetes (P = .14). Although food insecurity did not result in malnutrition or negatively impact wound healing time, it is important for providers to routinely screen for food insecurity due to increased nutritional requirements and loss of wages after burn injury.
Childhood epilepsy with centrotemporal spikes (CECTS) (formally benign epilepsy with centrotemporal spikes, BECTS) is a common childhood epilepsy syndrome characterized by psychiatric, behavioral, ...and cognitive abnormalities and self-limited seizures. Although CECTS is one of the most well-characterized electroclinical epilepsy syndromes, the natural history of neuropsychiatric outcomes is poorly understood. We report the psychiatric, behavioral, and cognitive profiles over the course of disease from a large, prospectively-enrolled, longitudinal cohort of children with CECTS. We further characterize the detailed seizure course and test the relationship between several proposed risk factors and neuropsychiatric and seizure outcomes in these children.
Patients diagnosed with CECTS were enrolled as part of a community-based study and followed from diagnosis through disease resolution (16.0 ± 3.1 years, N = 60). Twenty sibling controls were also recruited. We report the natural history of premorbid neuropsychiatric concerns, postmorbid neuropsychiatric diagnoses, long-term neuropsychological performance, seizure course, antiseizure medication (ASM) treatment response, and the relationship between duration seizure-free and remission. Age at onset and premorbid neuropsychiatric concerns were tested as predictors of seizure count, epilepsy duration, postmorbid neuropsychiatric diagnoses, and long-term neuropsychological performance. Antiseizure medication treatment duration, seizure count, and epilepsy duration were tested as predictors of postmorbid neuropsychiatric diagnoses and long-term neuropsychological performance.
Children with CECTS had a high incidence of ADD/ADHD symptoms (18.3%) or learning difficulties (21.7%) before diagnosis. New or persistent ADHD (20%), mood disorders (23.6%), learning difficulties (14.5%), and behavioral disorders (7.3%) were common after CECTS diagnosis. At 9-year follow-up, performance on formal neuropsychological testing was comparable to population statistics and sibling controls. More than two-thirds of treated children experienced at least one seizure during treatment. Most children (61.7%) had entered terminal resolution after 12 months seizure-free. Among all children, for each month seizure-free, there was a 6–7% increase in the probability of achieving terminal remission (p < 1e-10). The presence of a premorbid neurodevelopmental concern predicted a longer epilepsy duration (p = 0.02), higher seizure count (p = 0.02), and a postmorbid psychiatric or neurodevelopmental diagnosis (p = 0.002). None of the tested features predicted long-term neuropsychological performance.
Children are at high risk of neuropsychiatric symptoms along the course of the disease in CECTS, however, long-term cognitive performance is favorable. The majority of children had a seizure while being treated with ASMs, suggesting that CECTS is not as pharmacoresponsive as assumed or that treatment approaches are not optimized. Among treated and untreated children, future seizure-risk can be estimated from duration seizure-free. The presence of a premorbid neuropsychiatric concern predicted a more severe disease course in CECTS.
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•Children with CECTS are at high risk of neuropsychiatric symptoms.•Premorbid neuropsychiatric concern predicts comorbidities and worse seizure course.•Long-term neuropsychological outcome is favorable in CECTS.•Most children continue to have seizures during ASM treatment.•Duration seizure-free reliably predicts likelihood of terminal remission in CECTS.
The plain language summary explains age-related hearing loss to patients, families, and care partners. The summary is for any patient aged 50 years and older, families, and care partners. It is based ...on the 2024 "Clinical Practice Guideline: Age-Related Hearing Loss." This plain language summary is a companion publication to the full guideline, which provides greater detail for clinicians. Guidelines and their recommendations may not apply to every patient, but they can be used to find best practices and quality improvement opportunities.
Adult laying hens are increasingly housed in spatially complex systems, e.g., non-cage aviaries, where locomotion between elevated structures can be challenging for these gallinaceous birds. This ...study assessed the effect of early environmental complexity on spatial skills in two genetic strains. Brown (B) and white (W) feathered birds were raised in: Conventional cages with minimal complexity (Conv) or rearing aviaries with low (Low), intermediate (Mid), or high complexity (High). Birds from each housing treatment were challenged at three different time points in three different, age-appropriate vertical spatial tasks. Whites performed better than brown birds in all tests regardless of rearing environment. In chicks, test performance was predominantly explained by variation between replicates and differences in motivation for test participation. Treatment effects were seen in pubertal birds (pullets), with pullets from aviaries performing better than those from Conv. White High pullets performed better than white Mid or Low, an effect that was not found in browns. Pullets preferred to use a ramp to move downwards, but only when ramps had previously been experienced and when the ramp was not too steep. Overall, early environmental complexity affected spatial skills of laying hen pullets with stronger effects in white than brown feathered birds.
Abstract
There has been conflicting data on the relationship between burn severity and psychological outcomes. The present study aims to characterize the baseline psychosocial disposition of adults ...attending outpatient burn clinic at a large urban safety net hospital, as well as the impact of clinical course on self-reported psychosocial well-being. Adult patients attending outpatient burn clinic completed survey questions from the National Institutes of Health Patient-Reported Outcomes Measurement Information System Managing Chronic Conditions: Self-Efficacy for Managing Social Interactions (SEMSI-4) and Managing Emotions (SEME). Sociodemographic variables were collected from surveys and retrospective chart review. Clinical variables included total body surface area burned, initial hospital length of stay, surgical history, and days since injury. Poverty level was estimated by U.S. census data using patient’s home ZIP code. Scores on SEME-4 and SEMSI-4 were compared to the population mean by one-sample T-test, and independent variables evaluated for associations with managing emotions and social interactions by Tobit regression while adjusting for demographic variables. The 71 burn patients surveyed had lower scores in SEMSI-4 (mean = 48.0, P = .041) but not SEME-4 (mean = 50.9, P = .394) versus the general population. Marital status and neighborhood poverty level were associated with SEMSI-4, while length of stay and % total body surface area burned were associated with SEME-4. Patients who are single or from poorer neighborhoods may have difficulty interacting with their environment after burn injury and need extra social support. Prolonged hospitalization and increased severity of burn injury may have more impact on emotional regulation; these patients may benefit from psychotherapy during recovery.
Abstract
Disparities in psychosocial outcomes after burn injury exist in patients from racial or ethnic minority groups in the United States. Peer support groups can help patients with many ...psychosocial aspects of recovery from burns; however, access to such support among patients of racial and ethnic minority or low socioeconomic groups are unknown. The present study examined participation rates in outpatient peer support within this patient population. Patients attending outpatient clinic at an urban safety-net hospital and regional burn center with a majority minority patient population were asked about participation in burn survivor group, interest in joining a group, and given validated survey questions about managing emotions and social interactions since injury. Current or past participation in peer support was low (4.2%), and 30.3% of patients not already in support group were interested in joining. Interest in future participation in peer support was highest among Hispanic patients (37.0%) and lowest among Black patients (0%). Logistic regression models demonstrated that increased total body surface area burned, hospital length of stay, and need for surgical intervention were associated with interest in joining or having joined a peer support group. Effectiveness of management of emotions and social interactions were not associated with interest in joining peer support in the future. These findings demonstrate a considerable difference between levels of interest and participation in peer support within this population. Improving access to and education about benefits of peer support in underresourced communities may help to address the variation in psychosocial outcomes of patients across racial or ethnic minority groups recovering from burns.
BACKGROUND
Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive ...transfusion (UMT) (defined as ≥20 U of packed red blood cells RBCs) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era.
METHODS
An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014–2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality.
RESULTS
The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, −9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both
p
< 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14–26%), while absence of these factors was associated with the highest survival (71%).
CONCLUSION
Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication.
LEVEL OF EVIDENCE
Prognostic, level III.
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