Mollie Marr

Priorities for Pediatric Prehospital Research

Up to 3 million US children are cared for by emergency medical services (EMSs) annually. Limited research exists on pediatric prehospital care. The Pediatric Emergency Care Applied Research Network (PECARN) mission is to perform high-quality research for children, including prehospital research. Our objective was to develop a pediatric-specific prehospital research agenda. Methods: Representatives from all 4 PECARN nodes and from EMS agency partners participated in a 3-step process. First, participants ranked potential research priorities and suggested others. Second, participants reranked the list in order of importance and scored each priority using a modified Hanlon method (prevalence, seriousness, and practicality of each research area were assessed). Finally, the revised priority list was presented at a PECARN EMS summit, and consensus was sought. Results: Forty-two representatives participated, including PECARN representatives, EMS agency leaders, and nationally recognized prehospital researchers. Consensus was reached on the priority ranking. The prioritization processes resulted in 2 ranked lists: 15 clinical topics and 5 EMS system topics. The top 10 clinical priorities included (1) airway management, (2) respiratory distress, (3) trauma, (4) asthma, (5) head trauma, (6) shock, (7) pain, (8) seizures, (9) respiratory arrest, and (10) C-spine immobilization. The 5 EMS system topics identify methods to improve prehospital care on the system level. Conclusions: PECARN has identified high-priority EMS research topics for children using a consensus-derived method. These research priorities include novel EMS system topics. The PECARN EMS pediatric research priority list will help focus future pediatric prehospital research both within and outside the network.

Alcohol use by pedestrians who are struck by motor vehicles: How drinking influences behaviors, medical management, and outcomes

BACKGROUND Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. METHODS Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. RESULTS Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. CONCLUSION Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians.

Team Play in Surgical Education: A Simulation-Based Study

BACKGROUND Simulation-based training provides a low-stress learning environment where real-life emergencies can be practiced. Simulation can improve surgical education and patient care in crisis situations through a team approach emphasizing interpersonal and communication skills. OBJECTIVE This study assessed the effects of simulation-based training in the context of trauma resuscitation in teams of trainees. METHODS In a New York State-certified level I trauma center, trauma alerts were assessed by a standardized video review process. Simulation training was provided in various trauma situations followed by a debriefing period. The outcomes measured included the number of healthcare workers involved in the resuscitation, the percentage of healthcare workers in role position, time to intubation, time to intubation from paralysis, time to obtain first imaging study, time to leave trauma bay for computed tomography scan or the operating room, presence of team leader, and presence of spinal stabilization. Thirty cases were video analyzed presimulation and postsimulation training. The two data sets were compared via a 1-sided t test for significance (p < 0.05). Nominal data were analyzed using the Fischer exact test. RESULTS The data were compared presimulation and postsimulation. The number of healthcare workers involved in the resuscitation decreased from 8.5 to 5.7 postsimulation (p < 0.001). The percentage of people in role positions increased from 57.8% to 83.6% (p = 0.46). The time to intubation from paralysis decreased from 3.9 to 2.8 minutes (p < 0.05). The presence of a definitive team leader increased from 64% to 90% (p < 0.05). The rate of spine stabilization increased from 82% to 100% (p < 0.08). After simulation, training adherence to the advanced trauma life support algorithm improved from 56% to 83%. CONCLUSIONS High-stress situations simulated in a low-stress environment can improve team interaction and educational competencies. Providing simulation training as a tool for surgical education may enhance patient care.

Vulnerable roadway users struck by motor vehicles at the center of the safest, large US city

BACKGROUND Road safety constitutes an international crisis. In 2010, 11,000 pedestrians and 3,500 bicyclists were injured by motor vehicles in New York City. This study aims to identify the demographics, behaviors, injuries, and outcomes of vulnerable roadway users struck by motor vehicles in New York City’s congested central business district and surrounding periphery. METHODS A prospective, descriptive study of pedestrians and bicyclists struck by motor vehicles and treated at a Level I regional trauma center was performed. Data were collected between December 2008 and June 2011 by interviewing patients and first responders supplemented with imaging and outcomes variables. Main outcome measures included patient demographics, behavior patterns, scene-related data, Injury Severity Score (ISS), and outcomes including mortality. Multivariate ordinal logistic regression modeling was performed to isolate effects of predictor variables on outcome of ISS categories. RESULTS Injured pedestrians (n = 1,075) and bicyclists (n = 382) differ by age (p < 0.001), sex (p < 0.001), ethnicity/race (p < 0.001), and involved motor vehicle type (p < 0.001). Pedestrians sustain more severe/critical injuries (p < 0.001) and hospital admissions (p < 0.001). Bicyclists are more commonly struck by taxis (p < 0.001) and infrequently wear helmets (29.6%). Variables associated with low ISS include bicycling (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.29–0.63), above normal body mass index (AOR, 0.73; 95% CI, 0.54–0.99), Latino (AOR, 0.65; 95% CI, 0.46–0.94) or black (AOR, 0.63; 95% CI, 0.41–0.96) ethnicity/race, and struck by a taxicab (AOR, 0.50; 95% CI, 0.33–0.76) or turning vehicle (AOR,0.49; 95% CI, 0.34–0.70). Variables associated with high ISS include alcohol (AOR, 2.71; 95% CI, 1.81–4.05), age less than 18 years (AOR, 1.73; 95% CI, 1.05–2.86), hearing impairment (AOR, 2.24; 95% CI, 1.24–4.03), and struck by a truck or bus (AOR, 1.91; 95% CI, 1.18–3.10). Mortality was 1.2%. CONCLUSION Injured pedestrians and bicyclists represent distinct entities. Prevention modalities must be tailored accordingly with a focus on high-risk subgroups and compliance with traffic laws. Studying fatality or admissions data fail to capture the extent of the epidemic. LEVEL OF EVIDENCE Prospective epidemiologic study, level II.

Abstract 101: Pilot study of oral microbiome and risk of pancreatic cancer.

Proceedings: AACR 104th Annual Meeting 2013; Apr 6-10, 2013; Washington, DC Previous studies showed that periodontitis and tooth loss are associated with increased risk of pancreatic cancer, suggesting possible role of oral bacteria in the pancreatic cancer etiology. We evaluated whether oral microbiome is associated with risk of pancreatic cancer and pancreatitis. Oral wash samples were collected from 13 pancreatic cancer patients, 3 pancreatitis patients and 12 healthy controls at NYU Langone Medical Center, New York. Ribosomal 16S rRNA genes from oral wash DNA were amplified by universal primers, barcoded, and sequenced with 454 FLX technology. The bacterial 16S rRNA gene sequences were binned into operational taxonomic units (OTUs) with 97% identify and further classified by taxonomy. Non-parametric Wilcoxon Mann Whiteney U test and Kuskal-Wallis test were conducted to compare the relative abundance of taxa across pancreatic cancer, pancreatitis and control groups. A total of 250,008 sequence reads (average 8,928 reads per sample) were observed. Firmicutes, Bacteroidetes, and Actinobacteria are major phyla, accounting for 96.5% of oral microbiota. We found that bacteroides genus was significantly more abundant in both pancreatic cancer patients (p = 0.002) and pancreatitis patients (p = 0.004) compared with control group. Further, BLAST search results indicate that the species most closely represented by the Bacteroides OTUs were oral pathogen. In addition, Corynebacterium (p = 0.033) and Aggregatibacter (p = 0.019) were less abundant in pancreatic cancer and pancretitis groups compared with controls. Data from this pilot study of oral microbiome and pancreatic cancer suggest that the differential abundance in bacteriodates and possibly Corynebacterium and Aggregatibacter, are associated with risk of pancreatic cancer. Bacteroides, Gram-negative bacillus bacteria, plays an important role in oral inflammation, including periodontitis. Further larger studies are warranted to confirm these preliminary findings. Citation Format: I-Hsin Lin, Jing Wu, Steven M. Cohen, Calvin Chen, Darren Bryk, Mollie Marr, Marcovalerio Melis, Elliot Newman, H Leon Pachter, Alexander V. Alekseyenko, Richard B. Hayes, Jiyoung Ahn. Pilot study of oral microbiome and risk of pancreatic cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 101. doi:10.1158/1538-7445.AM2013-101

Utilization Patterns at a Specialized Children's Comprehensive Psychiatric Emergency Program

OBJECTIVE Most youths experiencing a psychiatric crisis present to emergency departments (EDs) that lack the specialized staff to evaluate them, so youths are often discharged without appropriate mental health assessment or treatment. To better understand the needs of this population, this study described clinical details and disposition associated with visits for psychiatric emergencies to a specialized ED staffed 24/7 by child psychiatrists. METHODS Through retrospective chart review, 1,180 visits to the ED during its first year of operation were reviewed for clinical characteristics, prior service utilization, and demographic characteristics. Bivariate analyses (chi-square test and Wilcoxon rank sum test) compared differences in disposition (evaluate and release, brief stabilization, and inpatient psychiatric admission) associated with characteristics of the childrens first visit (N=885). Measures with bivariate association of p<.10 were further assessed by using multinomial logistic regression analyses. RESULTS For most visits (59%), children were evaluated and released, 13% were briefly stabilized, and 28% were admitted for psychiatric treatment. Youths with mood or psychotic disorders were more likely to be admitted, as were those with current suicidality or aggression. Many youths who presented with aggression were also identified as having suicidality or self-harm. CONCLUSIONS Clinical factors, especially suicidality, predicted psychiatric admission. Admission rates for youths with suicidality were significantly higher in this study than previously reported, suggesting the availability of child psychiatrists in this ED allowed greater ascertainment of suicide risk (and thus hospitalization to mitigate that risk) than occurs in EDs without such staffing.

Trauma-Informed Care in Inpatient and Residential Settings

A history of exposure to traumatic events is the norm in youth utilizing residential care, whether it be acute or subacute inpatient care or longer-term residential placement. Studies of youth in inpatient psychiatric settings reveal traumatic exposures in over 90 % of admitted youth and rates of post-traumatic stress disorder (PTSD) from 25 to 33 % (Adam et al. 1992; Craine et al. 1988; Gold 2008; Havens et al. 2012a, b; Allwood et al. 2008; Lipschitz et al. 1999). By definition, youth placed within the child welfare system have been exposed to abuse and/or neglect. Studies in this population reveal rates of PTSD from 19 to 40 % (Kolko et al. 2010; Famularo et al. 1996). Despite these realitites, inpatient psychiatricand residential treatment settings often struggle to adeqautely identify and address trauma exposure and its mental health consequences in youth, leading to inadeqaute treatmetn planning and milieu management problems. This chapter describes the features of trauma-informed milieu settings and outlines the steps in implementing four essential component: 1) youth trauma screening processes; 2) multi-disciplinarystaff trauma training; 3) trauma skills groups for youth, and; 4) strategies for sustainability of trauma practices. Examples are provided from the authors’ experiences in implementing trauma-informed care in inpatient child and adolescent psychiatry and juvenile detneion settings