Paediatric trauma on the Last Frontier: an 11-year review of injury mechanisms, high-risk injury patterns and outcomes in Alaskan children

Background: Paediatric trauma system development in Alaska is complicated by a vast geographic coverage area, wide regional variations in environment and culture, and a lack of available published data. Objective: To provide a detailed description of paediatric trauma mechanisms, high-risk injury patterns and outcomes in Alaska. Design: This retrospective study included all children aged 17 years or younger in the State of Alaska Trauma Registry database admitted with traumatic injury between 2001 and 2011. Each injury record was reviewed individually and assigned a mechanism based on Centers for Disease Control E-codes. Geographic definitions were based on existing Emergency Medical Services regions. Mechanisms were compared by geographic region, patient demographics, injury characteristics and outcome. Subgroup analysis of fatal injuries was performed to identify causes of death. Results: Of 5,547 patients meeting inclusion criteria, the most common mechanisms of injury were falls (39%), motor vehicle collisions (10%) and all-terrain vehicle (ATV) accidents (9%). The overall case fatality rate was 2%. Mechanisms with the greatest risk of death were gunshot wounds (21%), pedestrians struck by motorized vehicles (9%) and motor vehicle collisions (5%). These 3 mechanisms accounted for 15% of injuries but 60% of deaths in the overall cohort. Injury patterns involving combined central nervous system (CNS) and torso injuries were unusual but especially lethal, occurring in 3% of patients but carrying a case fatality rate of 18%. Although the distribution of mechanisms was generally similar for each geographic region, ATV and snowmobile injuries were significantly more common in remote areas (23% remote vs. 7% non-remote, p < 0.0001). Conclusions: Mechanisms of paediatric trauma in Alaska have widely varying impacts on outcome and show some variation by region. Highest-risk mechanisms include gunshot wounds and motorized vehicle-related accidents. Prevention efforts should give special attention to CNS injury prevention, ATV and snowmobile safety in remote areas, and optimization of management of multisystem trauma. Further studies should investigate predictors of outcome in greater detail

Can fire atlas data improve species distribution model projections?

Correlative species distribution models (SDMs) are widely used in studies of climate change impacts, yet are often criticized for failing to incorporate disturbance processes that can influence species distributions. Here we use two temporally independent data sets of vascular plant distributions, climate data, and fire atlas data to examine the influence of disturbance history on SDM projection accuracy through time in the mountain ranges of California, USA. We used hierarchical partitioning to examine the influence of fire occurrence on the distribution of 144 vascular plant species and built a suite of SDMs to examine how the inclusion of fire-related predictors (fire occurrence and departure from historical fire return intervals) affects SDM projection accuracy. Fire occurrence provided the least explanatory power among predictor variables for predicting species’ distributions, but provided improved explanatory power for species whose regeneration is tied closely to fire. A measure of the departure from historic fire return interval had greater explanatory power for calibrating modern SDMs than fire occurrence. This variable did not improve internal model accuracy for most species, although it did provide marginal improvement to models for species adapted to high-frequency fire regimes. Fire occurrence and fire return interval departure were strongly related to the climatic covariates used in SDM development, suggesting that improvements in model accuracy may not be expected due to limited additional explanatory power. Our results suggest that the inclusion of coarse-scale measures of disturbance in SDMs may not be necessary to predict species distributions under climate change, particularly for disturbance processes that are largely mediated by climate

Modeling plant ranges over 75 years of climate change in California, USA: temporal transferability and species traits

Species distribution model (SDM) projections under future climate scenarios are increasingly being used to inform resource management and conservation strategies. A critical assumption for projecting climate change responses is that SDMs are transferable through time, an assumption that is largely untested because investigators often lack temporally independent data for assessing transferability. Further, understanding how the ecology of species influences temporal transferability is critical yet almost wholly lacking. This raises two questions. (1) Are SDM projections transferable in time? (2) Does temporal transferability relate to species ecological traits? To address these questions we developed SDMs for 133 vascular plant species using data from the mountain ranges of California (USA) from two time periods: the 1930s and the present day. We forecast historical models over 75 years of measured climate change and assessed their projections against current distributions. Similarly, we hindcast contemporary models and compared their projections to historical data. We quantified transferability and related it to species ecological traits including physiognomy, endemism, dispersal capacity, fire adaptation, and commonness. We found that non-endemic species with greater dispersal capacity, intermediate levels of prevalence, and little fire adaptation had higher transferability than endemic species with limited dispersal capacity that rely on fire for reproduction. We demonstrate that variability in model performance was driven principally by differences among species as compared to model algorithms or time period of model calibration. Further, our results suggest that the traits correlated with prediction accuracy in a single time period may not be related to transferability between time periods. Our findings provide a priori guidance for the suitability of SDM as an approach for forecasting climate change responses for certain taxa

Helmet use Among Alaskan Children Involved in off-road Motorized Vehicle Crashes

Background: Off-road motorized vehicle crashes are a common source of trauma among Alaska children. Injury morbidity is worse in Alaska Native children than non-Native children, but the reasons are unclear. Objective: To evaluate the differences in helmet use between the Native and the non-Native children, and to assess the impact of helmet use on injury patterns and outcomes. Design: This retrospective cohort study identified patients aged 17 or younger admitted after all-terrain vehicle, snowmobile or motorbike injury between 2001 and 2011 from the Alaska Trauma Registry. Helmeted and non-helmeted patients were compared with respect to demographics, central nervous system (CNS) injury and the overall risk of death or permanent disability. Logistic regression was used to evaluate predictors of helmet use and the effects of ethnicity and helmet use on outcomes. Results: Of the 921 injured children, 51% were Alaska Native and 49% were non-Native. Helmet use was lower among Native versus non-Native patients on unadjusted comparison (24% vs. 71%) and multivariable logistic regression (OR 0.17, 95% CI 0.11–0.27, p Conclusions: Helmet use is lower among Alaska Native children involved in off-road motorized vehicle crashes. These ethnic disparities in helmet use contribute to higher rates of CNS injury among Native children. Helmet use significantly improves overall outcome. Helmet promotion efforts should be expanded, especially in Native communities

Helmet use Among Alaskan Children Involved in off-road Motorized Vehicle Crashes

Background: Off-road motorized vehicle crashes are a common source of trauma among Alaska children. Injury morbidity is worse in Alaska Native children than non-Native children, but the reasons are unclear. Objective: To evaluate the differences in helmet use between the Native and the non-Native children, and to assess the impact of helmet use on injury patterns and outcomes. Design: This retrospective cohort study identified patients aged 17 or younger admitted after all-terrain vehicle, snowmobile or motorbike injury between 2001 and 2011 from the Alaska Trauma Registry. Helmeted and non-helmeted patients were compared with respect to demographics, central nervous system (CNS) injury and the overall risk of death or permanent disability. Logistic regression was used to evaluate predictors of helmet use and the effects of ethnicity and helmet use on outcomes. Results: Of the 921 injured children, 51% were Alaska Native and 49% were non-Native. Helmet use was lower among Native versus non-Native patients on unadjusted comparison (24% vs. 71%) and multivariable logistic regression (OR 0.17, 95% CI 0.11–0.27, p Conclusions: Helmet use is lower among Alaska Native children involved in off-road motorized vehicle crashes. These ethnic disparities in helmet use contribute to higher rates of CNS injury among Native children. Helmet use significantly improves overall outcome. Helmet promotion efforts should be expanded, especially in Native communities

Helmet use among Alaskan children involved in off-road motorized vehicle crashes

Background: Off-road motorized vehicle crashes are a common source of trauma among Alaska children. Injury morbidity is worse in Alaska Native children than non-Native children, but the reasons are unclear. Objective: To evaluate the differences in helmet use between the Native and the non-Native children, and to assess the impact of helmet use on injury patterns and outcomes. Design: This retrospective cohort study identified patients aged 17 or younger admitted after all-terrain vehicle, snowmobile or motorbike injury between 2001 and 2011 from the Alaska Trauma Registry. Helmeted and non-helmeted patients were compared with respect to demographics, central nervous system (CNS) injury and the overall risk of death or permanent disability. Logistic regression was used to evaluate predictors of helmet use and the effects of ethnicity and helmet use on outcomes. Results: Of the 921 injured children, 51% were Alaska Native and 49% were non-Native. Helmet use was lower among Native versus non-Native patients on unadjusted comparison (24% vs. 71%) and multivariable logistic regression (OR 0.17, 95% CI 0.11–0.27, p<0.0001). Prevalence of CNS injury was higher among Native children (39.7% vs. 30.4%, p=0.016). However, on logistic regression with adjustment for helmet use, Native ethnicity was not a significant predictor of CNS injury (OR 1.07, 95% CI 0.68–1.68, p=0.78), whereas helmet use was strongly protective against CNS injury (OR 0.28, 95% CI 0.18–0.44, p<0.0001) as well as death or permanent disability (OR 0.26, 95% CI 0.10–0.67, p=0.006). Conclusions: Helmet use is lower among Alaska Native children involved in off-road motorized vehicle crashes. These ethnic disparities in helmet use contribute to higher rates of CNS injury among Native children. Helmet use significantly improves overall outcome. Helmet promotion efforts should be expanded, especially in Native communities

Paediatric Trauma on the Last Frontier: an 11-year Review of Injury Mechanisms, High-risk Injury Patterns and Outcomes in Alaskan Children

Background: Paediatric trauma system development in Alaska is complicated by a vast geographic coverage area, wide regional variations in environment and culture, and a lack of available published data. Objective: To provide a detailed description of paediatric trauma mechanisms, high-risk injury patterns and outcomes in Alaska. Design: This retrospective study included all children aged 17 years or younger in the State of Alaska Trauma Registry database admitted with traumatic injury between 2001 and 2011. Each injury record was reviewed individually and assigned a mechanism based on Centers for Disease Control E-codes. Geographic definitions were based on existing Emergency Medical Services regions. Mechanisms were compared by geographic region, patient demographics, injury characteristics and outcome. Subgroup analysis of fatal injuries was performed to identify causes of death. Results: Of 5,547 patients meeting inclusion criteria, the most common mechanisms of injury were falls (39%), motor vehicle collisions (10%) and all-terrain vehicle (ATV) accidents (9%). The overall case fatality rate was 2%. Mechanisms with the greatest risk of death were gunshot wounds (21%), pedestrians struck by motorized vehicles (9%) and motor vehicle collisions (5%). These 3 mechanisms accounted for 15% of injuries but 60% of deaths in the overall cohort. Injury patterns involving combined central nervous system (CNS) and torso injuries were unusual but especially lethal, occurring in 3% of patients but carrying a case fatality rate of 18%. Although the distribution of mechanisms was generally similar for each geographic region, ATV and snowmobile injuries were significantly more common in remote areas (23% remote vs. 7% non-remote, p \u3c 0.0001). Conclusions: Mechanisms of paediatric trauma in Alaska have widely varying impacts on outcome and show some variation by region. Highest-risk mechanisms include gunshot wounds and motorized vehicle-related accidents. Prevention efforts should give special attention to CNS injury prevention, ATV and snowmobile safety in remote areas, and optimization of management of multisystem trauma. Further studies should investigate predictors of outcome in greater detail

Endoscopic biliary stent placement for anastomotic stricture following esophageal atresia repair in infant

Esophageal atresia is the most common congenital anomaly of the esophagus. Treatment optimally includes primary tension-free anastomosis of the upper and lower aspects of the esophagus. Distance between the upper and lower esophagus predisposes the anastomosis to tension, increasing the risk of anastomotic stricture. Esophageal stricture has historically been managed with repeated endoscopic balloon dilations. Multiple failed attempts at endoscopic balloon dilation requires surgical revision of the anastomosis. Stenting of esophageal stricture has been used in the adult population but has not been described for children. This case report demonstrates the placement of biliary stents in a 2-month-old infant with esophageal stricture following repair of a long gap Type C tracheoesophageal fistula. Successful stenting procedure averted the need for surgical revision