Concentrated Trauma Risk: Social and Environmental Determinants of Injury Mortality

Most Americans live within one hour of a Level I or II trauma center, but many rural, low income, and historically underrepresented minority communities lack access to appropriate trauma care services. Underserved populations tend to have higher injury incidence rates and mortality, but little is known about the role of trauma center access and injury scene characteristics as determinants of injury disparities. Using data from the Maryland Adult Trauma Registry and eMEDS Patient Care Reporting System, the goals of this dissertation were to 1) examine the role of the built and social environment at the injury scene as determinants of injury mortality using multilevel logistic regression, 2) identify patterns of injury scene characteristics associated with increased risk of injury mortality using latent class analysis, and 3) assess the role of environmental, social, and health characteristics as mediators of the effects of race, ethnicity, and sex on injury mortality. Manuscript one examined characteristics of the built and social environment at injury incident locations, while controlling for patient characteristics. Odds of death increased with increasing distance to the nearest trauma center and when the nearest trauma center was publicly-owned or designated as Level III. Odds of death also increased with increasing median age at the community level, and when per capita income was less than $25,000. Manuscript two identified eight patterns of injury scene characteristics, including rural, exurban, young middle suburb, aging middle suburb, inner suburb, urban fringe, high income urban core, and low income urban core. Injury mortality was highest at rural and low income urban core locations. Manuscript three examined potential mediators of the effects of race, ethnicity, and sex on injury mortality. Prehospital time, trauma center distance, injury mechanism, and insurance type fully mediated the effect of race. Trauma center distance, injury mechanism, and insurance type partially mediated the effect of ethnicity. Prehospital time, injury severity, and insurance type partially mediated the effect of sex. The results of these analyses suggest that features of the built and social environment at injury scenes are associated with injury mortality, and may contribute to disparities in injury outcomes

The national burden of orthopedic injury: Cross-sectional estimates for trauma system planning and optimization

Background: Management of orthopedic injuries is a critical component of comprehensive trauma care. As patterns of injury incidence and recovery change in the face of emerging injury prevention efforts and technologies and an aging US population, assessment of the burden of orthopedic injury is essential to optimize trauma system planning. We sought to estimate the incidence of orthopedic injury requiring emergency orthopedic surgery in the United States.Methods: Using nationally representative samples from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, we estimated the incidence of orthopedic injury, polytrauma with orthopedic injury, and emergency operative orthopedic procedures performed for the management of traumatic injury. We used multivariable logistic regression to identify patient, injury, and hospital characteristics associated with odds of emergency orthopedic surgery.Results: A total of 7,214,915 patients were diagnosed with orthopedic injury in 2013-2014, resulting in 1,167,656 emergency orthopedic surgical procedures. Fall-related injuries accounted for 51% of health care encounters and 61% of emergency orthopedic surgical procedures. Odds of emergency orthopedic surgery were 2.04 times greater for patients with polytrauma, compared with isolated orthopedic injury (P \u3c 0.001).Conclusions: The total burden or orthopedic injury in the United States is substantial, and there is considerable heterogeneity in demand for care and practice patterns in the orthopedic trauma community. Population-based trauma system planning and tailored care delivery models would likely optimize initial treatment, recovery, and health outcomes for orthopedic trauma patients

Northside neighborhood, Chapel Hill, Orange County : an action-oriented community diagnosis : findings and next steps of action

This document is the final report on an action-oriented community diagnosis (AOCD) of the Northside Neighborhood in Chapel Hill, North Carolina. The assessment was aimed at identifying the strengths and challenges of the Northside community as described by service providers and community members. The AOCD was conducted by a team of five graduate students from the University of North Carolina-Chapel Hill School of Public Health between September of 2004 and May of 2005. The student team was guided by Delores Bailey, a service provider and community member who served as the students’ community preceptor. Mrs. Bailey is the co-director of EmPOWERment Incorporate, and non-profit organization focusing on sustainable economic development in Northside and other communities. The team first attended community events to observe neighborhood dynamics and gain entrée. The team then examined secondary data about the neighborhood’s geography, history, demographics, economics, and education. After being approved by the School of Public Health’s Institutional Review Board (IRB), we conducted qualitative, key informant interviews with 11 service providers, 14 community members, and 2 youth focus groups to listen to issues of concern to them. After analyzing the data from these interviews and data from secondary sources, our team organized the results into broad domains. These were: economics, housing, crime, and community dynamics. Service providers and community members’ views on these domains were then expressed as themes for each domain. With input from a planning committee of community members and service providers, five themes were selected for discussion at a community forum. These selected domains were crime and safety, housing, economics, services for youth, and services for seniors. The Community Forum on May 10, 2005 was attended by 150 community members and service providers. The following action steps were recommended: Economics: Service providers and community members agreed that local businesses and local government should provide more opportunities for people to learn job skills. - Increasing awareness of programs currently offered by EmPOWERment, Inc. Investigating the state of vocational programs in Chapel Hill-Carrboro schools. Encouraging existing minority owned businesses to hire minority employees. Youth services: Community members and service providers feel that services, including those offered by Hargraves, are not meeting the needs of youth in the community. Ensuring Hargraves employees distribute information to parents. Deliver flyers to the Chapel Hill-Carrboro schools central office. Provide van transportation to meetings for parents. Organize more events for parents and children. Provide summer activities for children over the age of twelve. Petition the recreation commission for more teenage programs. Senior services: Community members and service providers feel that services, including those offered by Hargraves, are not meeting the needs of senior citizens. Mobilizing a committee to address the needs of senior citizens. Housing: Community members and service providers share a mutual concern for the current and future state of housing for long term resident of Northside. Creating a committee dedicated to addressing the many issues concerning housing. Compiling a list of current city codes (trash, noise, parking, landscaping). Creating standards specific to Northside from community meetings. Delegating accountability for deviations from standards. Publicizing the list to residents, landlords, and town officials. Crime and safety: Community members and service providers agreed that Northside is generally a safe neighborhood, but could be made safer by eliminating drug activity. Inviting neighbors to community watch meetings. Distributing information about meetings to churches and public housing communities. Placing the community patrol on the next community watch meeting agenda. It is our hope that this document will be of use to those concerned about the health and quality of life of people living and working in Northside.Master of Public Healt

Occupational Therapy Interventions for ADLs in Adults Post-TBI with Visual Symptoms: A Systematic Review

PURPOSE: Traumatic brain injury (TBI) is a leading cause of death and injury in the United States. In fact, it is estimated that 1.5 million Americans experience them every year (CDC, 2022). Visual impairments may be a symptom following TBI (Richman, 2014). This affects an individual’s ability to perform activities of daily living (ADLs) such as dressing, hygiene, and functional mobility, including the reading required for these activities. The purpose of this systematic review was to synthesize the evidence and intervention options within the scope of occupational therapy for adults post-TBI experiencing visual symptoms. DESIGN: We conducted a systematic review of the literature from 2002 to 2022 that included adults 18 years and older post TBI, had a measurable ADL outcome, and were within the scope of occupational therapy. METHOD: We reviewed 163 articles and abstracts from CINAHL, Cochrane, PubMed, and Scopus databases. Eighty-seven articles were retrieved for full review and seven met inclusion criteria. U.S. Preventative Task Force levels of certainty and grade definitions were used to describe the strength of evidence. RESULTS: Articles were themed by intervention type: oculomotor and compensatory scanning training, and training in device use. Five articles ranging from Level I-III evidence focused on oculomotor and compensatory scanning training and provide moderate strength of evidence to improve ADL performance post-TBI. Oculomotor and compensatory scanning training dosages ranged from 20 to 90 minutes sessions 1-2 times a week, for 4 to 11 weeks. Two articles, one each of Level II and III evidence, addressed training in device use, providing low strength of evidence to improve ADL performance post-TBI. These devices may include the BrainPort Vision Pro, prisms, a dichoptic device, or a cheiroscope with 4-10 hours of training. CONCLUSION: Based on moderate strength of evidence, we recommend routine use of oculomotor and compensatory scanning training for individuals experiencing visual symptoms post-TBI. Device use training should be done on a case-by-case basis due to low strength of evidence. Many of the interventions in this systematic review were exercise- rather than occupation-based. Rote eye exercises without link to occupation may be considered outside the occupational therapy scope of practice, therefore integration with occupation and collaboration with an eye care professional is important. Practitioners should consider collaborating with researchers to design occupation-based interventions that can be tested with larger sample sizes to determine effective interventions to improve ADL performance in adults post-TBI experiencing visual symptoms. Professional development can ensure occupational therapists have advanced training and education in oculomotor and compensatory scanning. IMPACT STATEMENT: Current research supports oculomotor and compensatory scanning training for adults post-TBI experiencing visual symptoms. Future research should continue to explore occupation-based interventions for this population to maximize visual function for performance of everyday activities. REFERENCES: Centers for Disease Control and Prevention. (2022, January 6). Multiple cause of death data on CDC wonder. Centers for Disease Control and Prevention. https://wonder.cdc.gov/mcd.html Richman, E. (2014, March). Traumatic brain injury and visual disorders: What every ophthalmologist should know. American Academy of Ophthalmology; EyeNet Magazine. https://www.aao.org/eyenet/article/traumatic-brain-injury-visual-disorders-what-every-2https://digitalcommons.unmc.edu/cahp_ot_sysrev/1001/thumbnail.jp

Factors Facilitating Acceptable Mammography Services for Women with Disabilities

Prior research has described general barriers to breast cancer screening for women with disabilities (WWD). We explored specific accommodations described as necessary by WWD who have accessed screening services, and the presence of such accommodations in community based screening programs

Effect of Observing Change from Comparison Mammograms on Performance of Screening Mammography in a Large Community-based Population

To evaluate the effect of comparison mammograms on accuracy, sensitivity, specificity, positive predictive value (PPV1), and cancer detection rate (CDR) of screening mammography to determine the role played by identification of change on comparison mammograms

Long-term patient-reported outcome measures after injury: National trauma research action plan (NTRAP) scoping review protocol

Background: A significant proportion of patients who survive traumatic injury continue to suffer impaired functional status and increased mortality long after discharge. However, despite the need to improve long-term outcomes, trauma registries in the USA do not collect data on outcomes or care processes after discharge. One of the main barriers is the lack of consensus regarding the optimal outcome metrics.Objectives: To describe the methodology of a scoping review evaluating current evidence on the available measures for tracking functional and patient-reported outcomes after injury. The aim of the review was to identify and summarize measures that are being used to track long-term functional recovery and patient-reported outcomes among adults after injury.Methods: A systematic search of PubMed and Embase will be performed using the search terms for the population (adult trauma patients), type of outcomes (long-term physical, mental, cognitive, and quality of life), and measures available to track them. Studies identified will be reviewed and assessed for relevance by at least two reviewers. Data will be extracted and summarized using descriptive statistics and a narrative synthesis of the results. This protocol is being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines.Dissemination: This scoping review will provide information regarding the currently available metrics for tracking functional and patient-reported outcomes after injury. The review will be presented to a multi-disciplinary stakeholder group that will evaluate these outcome metrics using an online Delphi approach to achieve consensus as part of the development of the National Trauma Research Action Plan (NTRAP). The results of this review will be presented at relevant national surgical conferences and published in peer-reviewed scientific journals

Genomic investigations of unexplained acute hepatitis in children

Since its first identification in Scotland, over 1,000 cases of unexplained paediatric hepatitis in children have been reported worldwide, including 278 cases in the UK1. Here we report an investigation of 38 cases, 66 age-matched immunocompetent controls and 21 immunocompromised comparator participants, using a combination of genomic, transcriptomic, proteomic and immunohistochemical methods. We detected high levels of adeno-associated virus 2 (AAV2) DNA in the liver, blood, plasma or stool from 27 of 28 cases. We found low levels of adenovirus (HAdV) and human herpesvirus 6B (HHV-6B) in 23 of 31 and 16 of 23, respectively, of the cases tested. By contrast, AAV2 was infrequently detected and at low titre in the blood or the liver from control children with HAdV, even when profoundly immunosuppressed. AAV2, HAdV and HHV-6 phylogeny excluded the emergence of novel strains in cases. Histological analyses of explanted livers showed enrichment for T cells and B lineage cells. Proteomic comparison of liver tissue from cases and healthy controls identified increased expression of HLA class 2, immunoglobulin variable regions and complement proteins. HAdV and AAV2 proteins were not detected in the livers. Instead, we identified AAV2 DNA complexes reflecting both HAdV-mediated and HHV-6B-mediated replication. We hypothesize that high levels of abnormal AAV2 replication products aided by HAdV and, in severe cases, HHV-6B may have triggered immune-mediated hepatic disease in genetically and immunologically predisposed children