Trends in pediatric-adjusted shock index predict morbidity in children with moderate blunt injuries

Purpose Trending the pediatric-adjusted shock index (SIPA) after admission has been described for children suffering severe blunt injuries (i.e., injury severity score (ISS) ≥ 15). We propose that following SIPA in children with moderate blunt injuries, as defined by ISS 10–14, has similar utility. Methods The trauma registry at a single institution was queried over a 7 year period. Patients were included if they were between 4 and 16 years old at the time of admission, sustained a blunt injury with an ISS 10–14, and were admitted less than 12 h after their injury (n = 501). Each patient’s SIPA was then calculated at 0, 12, 24, 36, and 48 h (h) after admission and then categorized as elevated or normal at each time frame based on previously reported values. Trends in outcome variables as a function of time from admission for patients with an abnormal SIPA to normalize as well as patients with a normal admission SIPA to abnormal were analyzed. Results In patients with a normal SIPA at arrival, elevation within the first 24 h of admission correlated with increased length of stay (LOS). Increased transfusion requirement, incidence of infectious complications, and need for in-patient rehabilitation were also seen in analyzed sub-groups. An elevated SIPA at arrival with increased length of time to normalize SIPA correlated with increased length of stay LOS in the entire cohort and in those without head injury, but not in patients with a head injury. No deaths occurred within the study cohort. Conclusions Patients with an ISS 10–14 and a normal SIPA at time of arrival who then have an elevated SIPA in the first 24 h of admission are at increased risk for morbidity including longer LOS and infectious complications. Similarly, time to normalize an elevated admission SIPA appears to directly correlate with LOS in patients without head injuries. No correlations with markers for morbidity could be identified in patients with a head injury and an elevated SIPA at arrival. This may be due to small sample size, as there were no relations to severity of head injury as measured by head abbreviated injury scale (head AIS) and the outcome variables reported. This is an area of ongoing analysis. This study extends the previously reported utility of following SIPA after admission into milder blunt injuries

Trends in pediatric adjusted shock index predict morbidity and mortality in children with severe blunt injuries

Purpose The utility of measuring the pediatric adjusted shock index (SIPA) at admission for predicting severity of blunt injury in pediatric patients has been previously reported. However, the utility of following SIPA after admission is not well described. Methods The trauma registry from a level-one pediatric trauma center was queried from January 1, 2010 to December 31, 2015. Patients were included if they were between 4 and 16 years old at the time of admission, sustained a blunt injury with an Injury Severity Score ≥ 15, and were admitted less than 12 h after their injury (n = 286). Each patient's SIPA was then calculated at 0, 12, 24, 36, and 48 h after admission and then categorized as elevated or normal at each time frame based upon previously reported values. Trends in outcome variables as a function of time from admission for patients with an abnormal SIPA to normalize as well as patients with a normal admission SIPA to abnormal were analyzed. Results In patients with a normal SIPA at arrival, 18.4% of patients who developed an elevated SIPA at 12 h after admission died, whereas 2.4% of patients who maintained a normal SIPA throughout the first 48 h of admission died (p < 0.01). Among patients with an elevated SIPA at arrival, increased length of time to normalize SIPA correlated with increased length of stay (LOS) and intensive care unit (ICU) LOS. Similarly, elevation of SIPA after arrival in patients with a normal initial SIPA correlated to increased LOS and ICU LOS. Conclusions Patients with a normal SIPA at time of arrival who then have an elevated SIPA in the first 24 h of admission are at increased risk for morbidity and mortality compared to those whose SIPA remains normal throughout the first 48 h of admission. Similarly, time to normalize an elevated admission SIPA appears to directly correlate with LOS, ICU LOS, and other markers of morbidity across a mixed blunt trauma population. Whether trending SIPA early in the hospital course serves only as a marker for injury severity or if it has utility as a resuscitation metric has not yet been determined

Natural resource wars in the shadow of the future: Explaining spatial dynamics of violence during civil war

Previous studies on natural resources and civil wars find that the presence of natural resources increases both civil conflict risk and duration. At the same time, belligerents often cooperate over resource extraction, suggesting a temporal variation in the contest over this subnational space. This study argues that parties fight over natural resources primarily when they expect that the conflict is about to end, as the importance of controlling them increases in the post-conflict setting. In contrast, belligerents that anticipate a long war have incentives to avoid fighting near natural resources since excessive violence will hurt the extraction, trade, and subsequent taxation that provide conflict actors with income from the resource. We test our argument using yearly and monthly grid-cell-level data on African civil conflicts for the period 1989–2008 and find support for our expected spatial variation. Using whether negotiations are underway as an indicator about warring parties’ expectations on conflict duration, we find that areas with natural resources in general experience less intense fighting than other areas, but during negotiations these very areas witness most of the violence. We further find that the spatial shift in violence occurs immediately when negotiations are opened. A series of difference-in-difference estimations show a visible shift of violence towards areas rich in natural resources in the first three months after parties have initiated talks. Our findings are relevant for scholarship on understanding and predicting the trajectories of micro-level civil conflict violence, and for policymakers seeking to prevent peace processes being derailed

Improving Support Of Breastfeeding At A Baby-Friendly™ Designated Hospital In Albuquerque, New Mexico

Purpose: Breastfeeding has conclusively proven to be the healthiest feeding option for infants. Baby-Friendly™designated hospitals and birthing centers follow the Ten Steps to Successful Breastfeeding, which are considered to be the gold standard for supporting mothers who wish to breastfeed. However, even a Baby-Friendly™designated hospital may have room for improvement. The University of New Mexico Hospital (UNMH) is an urban hospital serving a predominantly Hispanic and Native American population, and the majority of pediatric patients are covered by Medicaid. Despite its Baby-Friendly™ designation, UNMH had low rates of physician documentation of discussing the health impacts of breastfeeding in the postpartum setting and discussion of home visitation prior to discharge. We aimed to improve these measures using the Plan-Do-Study-Act (PDSA) model. Methods: We conducted this study from August 2018 to August 2019 in the UNMH Mother Baby Unit. Providers reviewed 61 to 86 charts for each of four medical record reviews (MRR). Based on the results of the first two MRRs, providers decided to focus on increasing home visitation referrals. After the third MRR, providers worked to increase discussion and documentation of the health impacts of breastfeeding. Changes made included creation of a discharge planning checklist, modifying admission and discharge templates, educating attending and resident physicians via emails, meetings, chart reviews, and bulletin boards in the team room, and adding home visitation referral forms to all patient charts. Results: Over the one year study period, rates of discussing home visitation status increased from 49.2% to 89.2%. The rates of discussing health impacts of breastfeeding increased from 31.1% to 86.5%. Conclusions: Implementation of these quality improvement measures resulted in substantial gains in several key breastfeeding metrics, despite having already earned the designation Baby-Friendly.™ All hospitals, including those that are designated Baby-Friendly™, should consider supporting breastfeeding through ongoing quality improvement initiatives