R. Sterling Haring

Ocular injury in the United States: Emergency department visits from 2006-2011.

INTRODUCTION Ocular complaints represent a sizeable burden to emergency departments, accounting for an estimated 2.4 million ED visits annually. We sought to characterise visits associated with ocular injury and examine factors contributing to inpatient admission. METHODS We searched the Nationwide Emergency Department Sample between 2006 and 2011 and identified cases in which patients presented with a primary or secondary diagnosis of ocular trauma. We described these cases according to age, sex, external mechanism of injury, payer status, and identified relationships between these variables. Logistic regression models were employed to identify crude and adjusted relative odds of admission to inpatient status based on patient demographics, mechanism of injury, payer status, and the existence of multiple injuries. RESULTS Between 2006 and 2011, a total of 5541,434 visits were made to EDs in the United States with a primary or other diagnosis of ocular trauma; ocular trauma was the primary diagnosis in 77.9% of these cases. Overall, mean age at presentation was 33.8 years and the majority of patients were male (64.8%). Male sex, older age, being struck by or against an object, the existence of multiple injuries, and Medicaid as a primary payer were all associated with significantly higher odds of hospital admission. DISCUSSION The distribution of primary external mechanism of injury suggested that individuals are at higher risks for different injury types at each successive stage of life. Age and injury mechanism were correlated with odds of admission to inpatient status, with the highest odds among older adults who had been injured by being struck by or against an object. CONCLUSIONS Ocular injury plays a substantial role in the ED. Further work is necessary to determine whether developing and implementing age- and sex-appropriate prevention strategies could reduce the incidence of ocular injury and reduce morbidity related to these types of injuries.

Epidemiology of Sports-Related Eye Injuries in the United States

Importance Ocular trauma can lead to lifelong sequelae, and sports-related ocular injuries have been shown to disproportionately affect the young. Studies quantifying and characterizing the incidence and type of injuries seen with sports-related ocular trauma may be useful for resource utilization, training, and prevention efforts. Objective To examine the emergency department (ED) burden of sports-related ocular trauma in the United States. Design, Setting, and Participants This retrospective, cross-sectional study examined the Nationwide Emergency Department Sample, containing data from approximately 30 million ED visits annually at more than 900 hospitals nationwide, from January 1, 2010, to December 31, 2013, to determine factors associated with sports-related ocular trauma. Main Outcomes and Measures Annual incidence of sports-related ocular trauma, broken down by age, sex, mechanism of injury, and related activity, as well as factors associated with short-term impaired vision. Results During the study period, 120 847 individuals (mean age, 22.3 years [95% CI, 21.9-22.7]; 96 872 males, 23 963 females, and 12 with missing data) presented with sports-related ocular trauma, which was the primary diagnosis in 85 961 patients. Injuries occurred most commonly among males (69 849 [81.3%]; 95% CI, 80.6%-81.9%) and occurred most frequently as a result of playing basketball (22.6%; 95% CI, 21.7%-23.6%), playing baseball or softball (14.3%; 95% CI, 13.7%-14.9%), and shooting an air gun (11.8%; 95% CI, 10.8%-12.8%). Odds of presentation to the ED with impaired vision were greatest for paintball and air gun injuries relative to football-related injuries (odds ratio, 4.75; 95% CI, 2.21-10.19 and 3.71; 95% CI, 2.34-5.88, respectively; P < .001). Conclusions and Relevance In our study, approximately 30 000 individuals presented annually to EDs in the United States with sports-related eye injuries; in more than 70% of these cases, eye injuries were the primary diagnosis. Activities involving projectiles pose the greatest risk for visual impairment in the short term, although long-term outcomes were unavailable.

Trends in incidence and severity of sports-related traumatic brain injury (TBI) in the emergency department, 2006–2011

Abstract Objective: To characterize and identify trends in sports-related traumatic brain injury (TBI) emergency department (ED) visits from 2006–2011. Methods: This study reviewed data on sports-related TBI among individuals under age 65 from the Nationwide Emergency Department Sample from 2006–2011. Visits were stratified by age, sex, injury severity, payer status and other criteria. Variations in incidence and severity were examined both between groups and over time. Odds of inpatient admission were calculated using regression modelling. Results: Over the period examined, 489 572 sports-related TBI ED visits were reported. The majority (62.2%) of these visits occurred among males under the age of 18. The average head Abbreviated Injury Severity score among these individuals was 1.93 (95% CI = 1.93–1.94) and tended to be lowest among those in middle school and high school age groups; these were also less likely to be admitted. The absolute annual number of visits grew 65.9% from 2006 until 2011, with the majority of this growth occurring among children under age 15. Hospitalization rates dropped 35.6% over the same period. Conclusion: Changes in year-over-year presentation rates vs. hospitalization rates among young athletes suggest that players, coaches and parents may be more aware of sports-related TBI and have developed lower thresholds for seeking medical attention.

The Epidemiology of Pediatric Head Injury Treated Outside of Hospital Emergency Departments

Background: Although head trauma–related deaths, hospitalizations, and emergency department visits are well characterized, few studies describe pediatric patients presenting outside of emergency departments. We compared the epidemiology and extent of healthcare-seeking pediatric (0–17 years) patients presenting in outpatient settings with those of patients seeking nonhospitalized emergency department care. Methods: We used MarketScan Medicaid and commercial claims, 2004–2013, to identify patients managed in two outpatient settings (physician’s offices/clinics, urgent care) and the emergency department. We then examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention–defined head trauma diagnoses, the extent of and reasons for post-index visit ambulatory care use within 30/90/180 days, and annual and monthly variations in head trauma trends. Outpatient incidence rates in 2013 provided estimates of the nationwide US outpatient burden. Results: A total of 1,683,097 index visits were included, representing a nationwide burden in 2013 of 844,660 outpatient cases, a number that encompassed 51% of healthcare-seeking head trauma that year and that substantially increased in magnitude from 2004 to 2013. Two-thirds (68%) were managed in outpatient settings. While demographic distributions varied with index-visit location, injury-specific factors were comparable. Seasonal spikes appeared to coincide with school sports. Conclusions: There is an urgent need to better understand the natural history of head trauma in the >800,000 pediatric patients presenting each year for outpatient care. These outpatient injuries, which are more than double the number of head trauma cases recorded in the hospital-affiliated settings, illustrate the potential importance of expanding inclusion criteria in surveillance and prevention efforts designed to address this critical issue.

Advocacy for booster seat legislation in Florida: a lesson in politics and policy formation

MVCs are a major contributor to child injury and death. Infant restraint seats and child booster seats have been shown to reduce the odds of severe injury or death when used correctly. While all states have mandated the use of these restraint systems, the age at which a child can be legally restrained using an adult seat belt varies from state to state. Efforts to strengthen Floridas weak child restraint laws have failed for more than a decade; in the 2014 legislative session, advocates succeeded in raising the states age requirement from 3 years to 5  years. While many factors contributed to this years success, some key elements included efficient communication of supporting data, a strong and broad advocacy network and the leveraging of election year political rivalries. Efforts to further strengthen the law will continue into future legislative sessions.

Conscious status is associated with the likelihood of trauma centre care and mortality in patients with moderate-to-severe traumatic brain injury

ABSTRACT Objective: To assess the relationship between The International Classification of Diseases, Ninth Revision, Clinical Modification-derived conscious status and mortality rates in trauma centres (TC) vs. non-trauma centres (NTC). Methods: Patients in the 2006–2011 Nationwide Emergency Department Sample meeting, The Centers for Disease Control and Prevention criteria for traumatic brain injury (TBI), with head/neck Abbreviated Injury Scale (AIS) scores ≥3 were included. Loss of consciousness (LOC) was computed for each patient. Primary outcomes included treatment at a level I/II TC vs. NTC and in-hospital mortality. We compared logistic regression models controlling for patient demographics, injury characteristics, and AIS score with identical models that also included LOC. Results: Of 66,636 patients with isolated TBI identified, 15,761 (23.6%) had missing LOC status. Among the remaining 50,875 patients, 59.0% were male, 54.0% were ≥65 years old, 56.7% were treated in TCs, and 27.3% had extended LOC. Patients with extended LOC were more likely to be treated in TCs vs. those with no/brief LOC (71.1% vs. 51.4%, p < 0.001). Among patients aged <65, TC treatment was associated with increased odds of mortality [Adjusted Odds Ratio (AOR) 1.79]; accounting for LOC substantially mitigated this relationship [AOR 1.27]. Similar findings were observed among older patients, with reduced effect size. Conclusion: Extended LOC was associated with TC treatment and mortality. Accounting for patient LOC reduced the differential odds of mortality comparing TCs vs. NTCs by 60%. Research assessing TBI outcomes using administrative data should include measures of consciousness.

Occupational Variation in End-of-Life Care Intensity:

Background: End-of-life (EOL) care intensity is known to vary by secular and geographic patterns. US physicians receive less aggressive EOL care than the general population, presumably the result of preferences shaped by work-place experience with EOL care. Objective: We investigated occupation as a source of variation in EOL care intensity. Methods: Across 4 states, we identified 660 599, nonhealth maintenance organization Medicare beneficiaries aged ≥66 years who died between 2004 and 2011. Linking death certificates, we identified beneficiaries with prespecified occupations: nurses, farmers, clergy, mortuary workers, homemakers, first-responders, veterinary workers, teachers, accountants, and the general population. End-of-life care intensity over the last 6 months of life was assessed using 5 validated measures: (1) Medicare expenditures, rates of (2) hospice, (3) surgery, (4) intensive care, and (5) in-hospital death. Results: Occupation was a source of large variation in EOL care intensity across all measures, before and after adjustment for sex, education, age-adjusted Charlson Comorbidity Index, race/ethnicity, and hospital referral region. For example, absolute and relative adjusted differences in expenditures were US

A Faculty-Student Mentoring Program to Enhance Collaboration in Public Health Research in Surgery

9991 and 42% of population mean expenditure (P < .001 for both). Compared to the general population on the 5 EOL care intensity measures, teachers (5 of 5), homemakers (4 of 5), farmers (4 of 5), and clergy (3 of 5) demonstrated significantly less aggressive care. Mortuary workers had lower EOL care intensity (4 of 5) but small numbers limited statistical significance. Conclusion: Occupations with likely exposure to child development, death/bereavement, and naturalistic influences demonstrated lower EOL care intensity. These findings may inform patients and clinicians navigating choices around individual EOL care preferences.

Tackling causes and costs of ED presentation for American football injuries: a population-level study

procedures among the veteran population, correlating with the previous study. Simple mastectomies and breastconserving operations significantly increased, although a lower overall proportion of partial mastectomies was seen comparatively. Modified radical mastectomies rates showed a decreased trend, although this was not statistically significant. The modest decrease in modified radical mastectomies may represent a lag in progressive treatment or lack of access, associated with delayed treatment requiring more aggressive resection. Systems with multidisciplinary breast cancer programs have shown reconstruction rates of approximately 50% to 60%.5 There are only 7 VA hospitals providing oncologic breast surgery, with reconstruction rates ranging from 26% to 42% since 2007. Although reconstruction rates are increasing, expanding designated breast oncology/surgery programs with multidisciplinary approaches to treatment within the VA may be necessary to meet rising demands and decrease the number of “fee out” services. Free-flap breast reconstructions are also rising in academia, shown by Kadle et al.6 Interestingly, there was an increase in free-flap reconstructions performed in the VA, although the number remained quite low. With the technical difficulty of microsurgical reconstruction, increasing the number of microsurgical trained plastic surgeons in the VA should be considered. As the number of women in the military rises, it will be crucial to improve breast cancer treatment and reconstruction for veterans. Initiatives to expand access to breast oncologic and reconstructive surgeons, enhancing facilities, and improving women’s services will be essential in providing future quality care.

Traumatic brain injury in the elderly: morbidity and mortality trends and risk factors

BACKGROUND American tackle football is the most popular high-energy impact sport in the United States, with approximately 9 million participants competing annually. Previous epidemiologic studies of football-related injuries have generally focused on specific geographic areas or pediatric age groups. Our study sought to examine patient characteristics and outcomes, including hospital charges, among athletes presenting for emergency department (ED) treatment of football-related injury across all age groups in a large nationally representative data set. METHODS Patients presenting for ED treatment of injuries sustained playing American tackle football (identified using International Classification of Diseases, Ninth Revision, Clinical Modification code E007.0) from 2010 to 2011 were studied in the Nationwide Emergency Department Sample. Patient-specific injuries were identified using the primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code and categorized by type and anatomical region. Standard descriptive methods examined patient demographics, diagnosis categories, and ED and inpatient outcomes and charges. RESULTS During the study period 397363 football players presented for ED treatment, 95.8% of whom were male. Sprains/strains (25.6%), limb fractures (20.7%), and head injuries (including traumatic brain injury; 17.5%) represented the most presenting injuries. Overall, 97.9% of patients underwent routine ED discharge with 1.1% admitted directly and fewer than 11 patients in the 2-year study period dying prior to discharge. The proportion of admitted patients who required surgical interventions was 15.7%, of which 89.9% were orthopedic, 4.7% neurologic, and 2.6% abdominal. Among individuals admitted to inpatient care, mean hospital length of stay was 2.4days (95% confidence interval, 2.2-2.6) and 95.6% underwent routine discharge home. The mean total charge for all patients was