Jonathan I. Groner

Objective The aim of this study was to determine how the COVID-19 pandemic affected patient demographics, injury mechanisms, interhospital transfers and mortality of patients with traumatic brain injuries (TBIs) treated in US emergency departments (EDs). Design This cross-sectional study analysed 2016–2020 Nationwide Emergency Department Sample (NEDS) data. Setting US EDs contained in the NEDS. Participants Participants were patients with moderate and severe TBI who visited the ED. Primary and secondary outcome measures Probability sampling design and survey weights generated nationally representative estimates of ED visits by patient demographics, hospital characteristics and COVID-19 diagnosis and the top four leading TBI causes. To assess COVID-19 impact, we calculated the per cent change of estimated TBI ED visits and disposition outcomes from 2016 to 2019 and 2019 to 2020, and proportion and 95% CI of injury severity groups and admitted/transfer by hospital type and trauma centre level. A multivariable logistic regression model identified the mortality OR by patient demographics, injury severity, hospital characteristics and COVID-19 positive diagnosis. Results In 2020, there were 527 123 ED visits nationally for TBI, 4.3% higher than 2016 but 1.0% lower than 2019. Patients with TBI transferring to short-term hospitals and other facilities increased by 16.0% and 18.2%, respectively, from 2016 to 2019 and were 3.7% and 14.1% higher in 2020 than in 2019. An estimated 3317 patients with TBI died (in ED or later in hospital) in 2020, which is 9.8% higher than 2019. Firearm-related TBI proportion was 15.1% higher in 2020 than in 2019. Patients with TBI with injury severity scores 25–75 were significantly higher at nontrauma (29.4% vs 31.9 %) and level III trauma centres (34.9% vs 38.2%) in 2020 than in 2019. Patients with TBI treated at rural hospitals had significantly higher odds of mortality (OR=1.95, CI=1.58–2.40) than those at urban hospitals. Conclusions TBI patient mortality was higher at all US hospital types and almost all trauma centre levels in 2020 than in 2019. Patients with TBI treated at rural hospitals had a significantly higher mortality risk.

Bicycling is a common childhood activity that is associated with significant injury risk. This study’s aim was to assess pediatric bicycle injury epidemiology and impacts of the COVID-19 pandemic. We conducted a cross-sectional evaluation of patients age < 18 years presenting with bicycle injury to a pediatric trauma center. A pre-pandemic period (1 March 2015–29 February 2020) was compared to the pandemic period (1 March 2020–28 February 2021). A total of 611 injury events for children < 18 years were included (471 pre-pandemic events and 140 pandemic events). The relative frequency of pandemic injuries was greater than pre-pandemic injuries (p < 0.001), resulting in a 48% increase in pandemic period injuries versus the pre-pandemic average (141 pandemic vs. 94.4/year pre-pandemic). Individuals of female sex represented a larger proportion of injuries in the pandemic period compared to the pre-pandemic period (37% pandemic vs. 28% pre-pandemic, p = 0.035). Injuries were more common on weekends versus weekdays (p = 0.01). Time series analysis showed a summer seasonality trend. Localizing injury events to ZIP codes showed regional injury density patterns. During COVID-19, there was an increase in bicycle injury frequency and proportional shift toward more injuries involving individuals of female sex. Otherwise, injury patterns were largely unchanged. These results demonstrate the necessity of safety interventions tailored to community needs.

Statement of Purpose Virtual reality (VR) is effective and safe for managing acute pain in hospital settings. However, evidence about effectiveness and safety of VR for pain management during care transition from medical settings to at-home care is lacking. This project developed a VR pain management protocol and tested effectiveness of VR for home burn care pain management. Methods/Approach This randomized clinical trial was conducted at a large children’s hospital between October 29, 2019 and June 2020. A total of 24 pediatric burn patients (5–17 years) were recruited and randomly assigned to the intervention (active VR; n=11) or control group (n=13). Participants were asked baseline questions about their prior experience playing video games. Participants and guardians were given up to 8 surveys, to be completed each time a dressing change was necessary for up to 7 days and these surveys were then returned by mail in a pre-paid, self-addressed envelope. Results In the VR-PAT group, child and caregiver reported pain decreased as the week of dressing changes progressed and was lower than those in the control group after the fourth dressing change. All children in the VR group reported their satisfaction with the VR-PAT after each dressing. As dressing changes progressed over the study period (one week), children reported increased VR realism and more engagement with the VR-PAT. Both realism and engagement started at a mean of >6 at the first dressing and increased to >7–8 at the last dressing. Children’s happiness and fun also stayed constant across the week of dressings. Only two families reported some challenges in downloading or setting up VR game, but the technical issue was resolved quickly. None reported serious adverse events. Conclusion VR has a potential for being an effective and safe pain management tool during home burn care.

BACKGROUND: In 2016, the National Academies of Sciences, Engineering, and Medicine trauma report recommended a National Trauma Research Action Plan to “strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes.” With a contract from the Department of Defense, the Coalition for National Trauma Research created 11 expert panels to address this recommendation, with the goal of developing a comprehensive research agenda, spanning the continuum of trauma and burn care. This report outlines the work of the group focused on pediatric trauma. METHODS: Experts in pediatric trauma clinical care and research were recruited to identify gaps in current clinical pediatric trauma research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. Using successive surveys, participants were asked to rank the priority of each research question on a 9-point Likert scale categorized to represent priority. Consensus was defined as >60% agreement within the priority category. Priority questions were coded based on a dictionary of 118 National Trauma Research Action Plan taxonomy concepts in 9 categories to support comparative analysis across all panels. RESULTS: Thirty-seven subject matter experts generated 625 questions. A total of 493 questions (79%) reached consensus on priority level. Of those reaching consensus, 159 (32%) were high, 325 (66%) were medium, and 9 (2%) were low priority. The highest priority research questions related to surgical interventions for traumatic brain injury (intracranial pressure monitoring and craniotomy); the second highest priority was hemorrhagic shock. The prehospital setting was the highest priority phase of care. CONCLUSION: This diverse panel of experts determined that most significant pediatric trauma research gaps were in traumatic brain injury, hemorrhagic shock, and the prehospital phase of care. These research domains should be top priorities for funding agencies. LEVEL OF EVIDENCE: Therapeutic / Care Management; Level IV.

Background: Traumatic brain injury (TBI) poses a significant threat to children’s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. Objective: This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. Methods: The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. Results: Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. Conclusions: This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI.

BACKGROUND Traumatic brain injury (TBI) poses a significant threat to children’s health. Cognitive rehabilitation for pediatric TBI has the potential to improve the quality of life following the injury. Virtual reality (VR) can provide enriched cognitive training in a life-like but safe environment. However, existing VR applications for pediatric TBIs have primarily focused on physical rehabilitation. OBJECTIVE This study aims to design and develop an integrative hardware and software VR system to provide rehabilitation of executive functions (EF) for children with TBI, particularly in 3 core EF: inhibitory control, working memory, and cognitive flexibility. METHODS The VR training system was developed by an interdisciplinary team with expertise in best practices of VR design, developmental psychology, and pediatric TBI rehabilitation. Pilot usability testing of this novel system was conducted among 10 healthy children and 4 children with TBIs. RESULTS Our VR-based interactive cognitive training system was developed to provide assistive training on core EF following pediatric TBI. Pilot usability testing showed adequate user satisfaction ratings for both the hardware and software components of the VR system. CONCLUSIONS This project designed and tested a novel VR-based system for executive function rehabilitation that is specifically adapted to children following TBI.

The lifetime prevalence of self-inflicted harm amongst adolescents has been estimated to be as high as 60%, however these behaviors may begin in the younger child. Understanding the intentionality of a burn is critical in directing mental health recommendations for these patients. The purpose of this study is to compare patient and burn characteristics of children with unintentional and self-inflicted burns in a national sample. Data were obtained from the 2006–2014 National Inpatient Sample which is a 20-percent stratified sample of all U.S. community discharges developed for the Healthcare Cost and Utilization Project. Weighting was used to make national estimates for children 8–17 years old. Patients hospitalized with unintentional burn injuries were compared to those with self- inflicted burns using chi-square analyses for the categorical variables and a t-test for length of stay. Self-inflicted burns were seen in hospitalized children as young as 8 years old. Between 2006 and 2014, there were an estimated 24,707 children 8–17 years old admitted with burns: unintentional (67.0%), self-inflicted (3.2%), abuse/neglect/assault (1.1%), and undetermined intent (28.7%). When compared with those with unintentional burns, children with self-inflicted burns were significantly more likely to be female (59% vs. 35%), white (72% vs. 53.2%), older (70% >14 years vs. 34%), have a higher median household income by zip code, and be privately insured (all p-values ≤ 0.0001). Self-inflicted burns were more likely to be of the upper limb excluding the wrist and hand and were less severe than accidental burns. Children with self-inflicted burns had a median length of stay of 5.2 days vs. 2.9 for those with unintentional burns (p=0.07) and were more often discharged to non-acute care facilities (13% vs. 1%, p<0.0001). In a large national sample of children admitted with burns, those with self-injurious behaviors were more likely to be female and of a higher socioeconomic status. It is imperative to understand the intentionality of burns to facilitate timely treatment of this population and prevent further sequelae of self-injurious behaviors including suicide. Understanding the intentionality of burns will better inform medical providers on the mental health care needs of patients and prevention of subsequent self-harm and potential for suicidality.