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

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

US civilian active shooter incidents involving a semiautomatic rifle are more lethal than incidents involving other firearms

[Extract] In their study entitled, "Wounding patterns based on firearm type in civilian public mass shootings in the United States," the authors concluded that "civilian public mass shooting events with a handgun are more lethal than those associated with the use of a rifle." This conclusion is not supported by the results reported by the authors or by previously published literature on this topic

Validation of zip code-based estimates of ambulance driving distance to control for access to care in emergency surgery research

This study uses Medicaid data files to estimate the association of estimated driving distance and reported driven ambulance miles from an injury site to a hospital during emergency medical service calls as a means to assess data accuracy for use in future research