Using modified Delphi method to propose and validate the components of a child injury surveillance system for Iran

Purpose: Child injuries are a public health concern globally. Injury surveillance systems (ISSs) have beneficial impact on child injury prevention. There is a need for evidence-based consensus on frameworks to establish child ISSs. This research aims to investigate the key components of a child ISS for Iran and to propose a framework for implementation. Methods: Data were gathered through interview with experts using unstructured questions from January 2017 to December 2018 to identify child ISS functional components. Qualitative data were analyzed using content analysis method. Then, modified Delphi method was used to validate the functional components. Based on the outcomes of the content analysis, a questionnaire with closed questions was developed and presented to a group of experts. Consensus was achieved in two rounds. Results: In round I, 117 items reached consensus. In round II, 5 items reached consensus and were incorporated into final framework. Consensus was reached for 122 items comprising the final framework and representing 7 key components: goals of the system, data sources, data set, coalition of stakeholders, data collection, data analysis and data distribution. Each component consisted of several subcomponents and respective elements. Conclusion: This agreed framework will assist in standardizing data collection, analysis and distribution, which help to detect child injury problems and provide evidence for preventive measures.     

Snowmobile injuries and fatalities in children

Background/Purpose: Snowmobiling is a popular form of wintertime recreation but can be associated with significant morbidity and mortality. To better understand snowmobile trauma in children, medical records were reviewed, evaluating the relationships between demographic data, mechanisms, and resultant injuries. In addition, because prior studies of childhood snowmobile fatalities have reviewed only national databases, state and national data were combined to evaluate possible underreporting. Methods: Medical records were reviewed of children [le ]17 years old admitted to one trauma center between 1991 and 2000 with snowmobile-related injuries. Demographics, helmet usage, driver versus passenger, mechanism, injuries, injury severity score (ISS), and outcome data were recorded. Statistical analyses were performed to identify relationships between potential causative factors and ISS. State mortality data were acquired from state agencies and 2 databases of the U.S. Consumer Product Safety Commission (CPSC). Data from the 3 sources were compared, and a single list of fatalities was compiled and evaluated. Results: Thirty-one children (65% boys; mean age, 12 years) were admitted with snowmobile-related injuries. Fifty-two percent were driving the snowmobile. Helmet usage was 68%. The most common mechanisms were collisions with a fixed object (42%) and with a motor vehicle (35%). The head was the most commonly injured site (71%) followed by the extremities (58%). ISS ranged from 1 to 38 (median, 10). Increased age and the child driving were the only factors associated with increased ISS (P [lt ] .05). One child died of a massive head injury. Twenty-two fatalities (70% boys; mean age, 14 years) statewide were identified from state and national databases, only 12 of which were identified by the CPSC Death Certificate file. Head injury was the most common cause of death. Conclusions: Reckless snowmobiling leads to significant morbidity and mortality among children. Prior reports based on CPSC data likely underestimated the number of snowmobile-related fatalities. Our findings support previous American Academy of Pediatrics recommendations, including the restriction of snowmobile driving by children under 16, graduated licensing for older children, and universal helmet usage. J Pediatr Surg 38:784-787. [copy ] 2003 Elsevier Inc. All rights reserved.     

Evolution, not revolution: splenic salvage for blunt trauma in a statewide voluntary trauma system--a 10-year experience

BACKGROUND: State-legislated trauma systems have been enacted in an attempt to improve trauma care. Blunt splenic injury incidence without a legislated trauma system was examined for changes in care with a hypothesis that a voluntary system may perform equally with a legislated system. METHODS: Data from a statewide discharge database for the years 1993 to 2002 were examined. RESULTS: There were 276,425 trauma admissions overall, with blunt splenic injury occurring in 1.76%. Average Injury Severity Score (ISS) increased in trauma centers and decreased in the community. Trauma centers (TC) had more multisystem injuries. Splenic injury diagnosis increased 44% in TC between the early and late periods but only 7% in community facilities. Splenectomies increased 16% in TC but declined 16% in community hospital. Splenic salvage rate improved at both types of facilities. CONCLUSIONS: Splenic salvage rates improved over time in hospitals with no formal trauma system. Community hospitals cared for more than 50% of splenic injuries but transferred complex multisystem injuries, including splenic injuries, suggesting evolving care. Non-invasive imaging has increased the recognition of splenic injuries in both community hospitals and TC. Splenectomies are performed less, but have increased in TC with increasing ISS scores.     

Advantage of surgical intensive care unit (SICU) predominant by cardiothoracic surgeons in multiple trauma management in a primary hospital

Purpose It is a challenge for the primary hospitals to manage multiple trauma patients.In this article,we explored the advantage of establishing a surgical intensive care unit(SICU)predominant by cardiothoracic surgeons in the early management of multiple trauma.Methods This was a retrospective study and patients with multiple trauma in our hospital were collected and divided into two groups,based on time period and treat modes:group A(retrospective observation group)where patients were treated with the traditional treatment mode from January 2017 to December 2017 and group B(study group)where patients were treated in the SICU predominant by cardiothoracic surgeons from January 2018 to December 2018.Clinical data including demographics,injury severity score(ISS),causes of injury,time intervals from reception to entering SICU or operating room and mortality three days after injuries were collected.Data were analyzed by SPSS 20.0 software.Categorical variables were presented as number and/or frequency and continuous variables as mean±SD.Results Altogether 406 patients were included in this study,including 217 patients in group A and 189 patients in group B.General data between the two groups revealed no significant difference:mean age(years)(35.51±12.97 vs.33.62±13.61,p=0.631),gender distribution(mean/female,130/87 vs.116/73,p=0.589)and ISS(15.92±7.95 vs.16.16±6.89,p=0.698).Fall from height were the dominant mechanism of injury,with 135 cases in group A(71.4%)and 121 cases in group B(55.8%),followed by traffic accidents.Injury mechanism showed no significant differences between two groups(p=1.256).Introduction of the SICU significantly improved the care of trauma patients,regarding speed and mortality.Time intervals between reception and entering SICU or operating room was(108.23±6.72)min and(45.67±7.96)min in group A and B,respectively(p=0.001).Mortality three days after injuries was 13.89%and 5.53%in group A and B,respectively(p=0.005).Conclusion Establishing a SICU predominant by cardiothoracic surgeons can reduce the early mortality rates in multiple trauma patients.     

Spectrum of ocular injuries in children with major trauma

BACKGROUND: Few studies document the variety of ocular injuries encountered in children after major trauma. This study was performed to determine the type and frequency of ocular injuries in a large population of children with major trauma. METHODS: All children with ocular and adnexal injuries (n = 7497) among 96,879 children registered in the National Pediatric Trauma Registry (NPTR) were analyzed. Children were stratified for Injury Severity Score (ISS is a method for categorizing patients with multiple injuries in which an ISS > 15 is considered major trauma), age, sex, injury, protective restraint, vision threatening injury, and basilar skull fracture. RESULTS: Nearly 8% of the children in the NPTR sustained an ocular injury. These children had one or more injuries to one or both eyes and/or the ocular adnexa for an average of 1.3 ocular injuries per child. Three-fourths (75%) of the children with an ocular injury had an ISS < or = 15 and one-fourth (25%) had an ISS > 15. Among children with an ISS > 15 the most common injuries were orbital wall fracture (59%) and contusion of the eye and ocular adnexa (18%). Among these same children with an ISS > 15, the percent of orbital wall fractures, injuries to the optic nerve, and injuries to the other ocular cranial nerves doubled while the percent of basilar skull fractures tripled when compared with children with an ISS < or = 15. Penetrating injuries of the globe were significantly lower in children with an ISS > 15 than in children with an ISS < or = 15. Over 70% of the children with an eye injury and an ISS > 15 sustained injury in an accident involving a motorized or non motorized vehicle, and over 75% of those who could have been restrained, were not restrained. CONCLUSIONS: Children with an ocular injury sustained during major trauma (ISS > 15) are more likely to have a basilar skull fracture, orbital wall fracture, and a contusion of the eye and/or the ocular adnexa as compared with children with ISS < or = 15. Children with any of these injuries sustained during major trauma should be afforded prompt ophthalmologic evaluation to uncover injury to components of the visual system.     

Analysis of 274 patients with extremity injuries caused by the Bam earthquake

Objective: The extremity injury pattern after a major earthquake is not well understood because data on this type of injury and management are limited. The aim of this study was to analyze the data of trauma patients with ex-tremity injury in the earthquake of Barn Iran, registering 6.6 on the Richter scale.Methods: We reviewed medical records of 486 patients admitted to hospitals of Tehran University of Medical Sciences. Among them, 274 patients sustained extremity injuries. This group was composed of 138 females (50.4%) and 136 males (49.6%) and 213 cases (77.7%) were under 40 years of age.Results: Fracture was the major type of injury (58.4% of extremity injuries). The most common sites of injury were lower extremities (185 patients, 67.5% of all victims). Pelvic & rib fractures and abdominal injuries were the most fre-quently associated injuries. The mean ISS was 6.2±4.0, and 61% of the patients had ISS≤7. Amputation and death occurred in 2.9% and 2.5% of cases, respectively.Conclusions: Special attention should be given to deal-ing with orthopedic injuries in similar disasters in the future.     

Application of injury severity score to multiple injuries headed by spinal cord injury

Objective： To evaluate the application of injury severity score （ISS） to multiple injuries headed by spinal cord injury. Methods： The data of 55 cases （40 males and 15 females, aged 17-69 years, mean = 41 years） of multiple injuries headed by spinal cord injury treated in our hospital from January 2000 to December 2004 were reviewed and analyzed with ISS （Version of AIS-2005 ） to explore their relationship. Results ： The ISS values increased with the number of injured regions, so did the complications. The recovery rate was negatively related to ISS values. During the period of immunity observation, the patients with ISS 〉 25 could undergo planned operations safely. Conclusions： Treatment for multiple injuries headed by spinal cord injury closely depends on the general and local conditions of the patients. ISS may provide useful data for the choice of treatment methods.     

Accuracy of administrative data in trauma.

BACKGROUND: Accurate data are needed to evaluate outcomes, therapeutics, and quality of care. This study assesses the accuracy of administrative databases in recording information about trauma patients. METHODS: Patients with thoracic aorta injury were identified with a state trauma registry, and the medical records were reviewed. Data collected were compared to administrative data on patients with thoracic aorta injuries, at the same hospitals in the same time period. RESULTS: Fifteen patients (16.3%) with thoracic aorta injury were not recorded in the administrative database, and 23 patients (18.7%) were misdiagnosed. Ninety-one patients were found in both data sources. The administrative database significantly (P < .05) underrecorded abdominal injuries (50 vs 35), orthopedic injuries (117 vs 75), and chest injuries (77 vs 48). The number of aortograms (78 vs 8), type of operative procedures (use of graft; 70 vs 30), use of bypass (35 vs 16), and complications (77 vs 33) were underreported (P < .05). The Injury Severity Score was underestimated by the administrative database (38.65 +/- 12.41 vs 25.66 +/- 9.53; P < .05). CONCLUSIONS: Administrative data lack accuracy in the recording of associated injury, injury severity, diagnostic, and procedural data. Whether these data should be used to evaluate treatment or quality of care in trauma is questionable.     

The establishment of a Jamaican all-injury surveillance system

The impact of injuries on the Jamaican health care system is a growing problem. Based on the successful implementation of a Violence-Related Injury Surveillance System (VRISS) in the Accident and Emergency (A&E) department of the Kingston Public Hospital (KPH), Ministry of Health (MOH) officials decided to expand the system to the Jamaica Injury Surveillance System (JISS), allowing for the surveillance of both intentional and unintentional injuries. A working group designed the expanded injury surveillance system based on the International Classification of External Causes of Injury. The expanded system allowed for the collection of data on all injuries seen in the A&E departments by adding four injury projects to the computerized A&E registration process. These were (1) unintentional injury, (2) violence-related injury, (3) suicide attempt (also known as intentional self-harm) and (4) motor vehicle-related injuries. The expanded JISS was implemented at the KPH and four additional hospitals across the island. The geographic distribution of these hospitals provided a reflection of rural and urban, highland and coastal communities and their distinctive injury profiles. Data collected at registration were printed on trauma sheets and reviewed by medical staff before being incorporated into the patient's record. Monthly reports detailing demographics and summary statistics were generated and made available at the local and national level. By monitoring the national injury profile, the JISS provides data to support needed policy changes to minimize the impact of injuries on the health services and on the health of the population.     

Analysis of chest injuries sustained during the 1999 Marmara earthquake

Purpose: The chest injury pattern after a major earthquake is not well understood because data on the type of trauma and surgical intervention are limited. This study was conducted to analyze patients who sustained chest injury during the Marmara earthquake that struck Turkey on August 17, 1999 registering 7.4 on the Richter scale. Methods: The medical reports of 528 patients transported to a military hospital in the first 48 h after the earthquake were reviewed. Two chest surgeons examined these 528 patients, 19 of whom (4%) had suffered a major chest injury. We retrospectively evaluated the injury pattern, Abbreviated Injury Score (AIS), and Injury Severity Score (ISS) in these 19 patients. Results: Eight patients (42%) had isolated chest injuries and 11 (58%) had suffered injury to more than one organ system, including chest trauma. The mean AIS and ISS were assigned as 2.9 (SD: 1) and 22 (SD: 7), respectively. Three (16%) of the 19 patients died, all of whom had suffered multiple injuries. The mean ISS of these three patients was 28.7 (range 25–34). Chest injury after a major earthquake was associated with an overall mortality rate of 16%, but chest injury with multiple injuries and an ISS over 25 was associated with a mortality rate of 60%. All patients with isolated chest injuries survived. Conclusion: Coexistent trauma with chest injury and an ISS over 25 were defined as poor prognostic factors for patients rescued after a major earthquake. Received: April 16, 2001 / Accepted: March 5, 2002     

Perceptions of care access: the experience of rural and urban women following brain injury

To examine care access among women with brain injuries, a qualitative, phenomenological study was conducted. Twenty one women with acquired brain injuries were recruited for the inquiry, representing rural and urban regions of Colorado. The phenomenological approach allowed the investigators to examine the shared experiences of women with brain injuries as they sought rehabilitative supports and services, and attempted to re enter their lives and communities. Each woman was interviewed one or two times, the interviews were transcribed and then coded and analysed by both authors separately. Thematic analysis of the data revealed two major emergent themes: issues surrounding diagnosis and barriers to accessing care. A total of 10 women interviewed experienced difficulty obtaining a diagnosis of brain injury and experienced serious personal and professional consequences as a result. All the women experienced barriers to accessing care, including problems with service providers and service systems, financial challenges, travelling for services, lack of information or services in their area, lack of care coordination and funnelling. Some of the barriers cannot be changed secondary to cost, efficiency and logistics. Other barriers, could be changed through education, training and policy making.     

Chest injury in victims of Bam earthquake

Objective:To analyze the data of trauma patients with thoracic injury in the earthquake of Bam admitted to hospitals of Tehran University of Medical Science (TUMS) for better understanding the type and consequence of thoracic injuries in a major earthquake. Methods:After Bam earthquake registering 6.5 on the Richter scale, 526 trauma patients were admitted to hospitals of TUMS. Among them, 53 patients sustained thoracic injury. Results: This group was composed of 21 females (39.6%) and 32 males (60.4%). Fifteen patients (28.3%) had isolated chest injuries. Rib fracture (36.4%) was the most common injury in our patients and haemo/pneumothorax (25.5%) followed. Superficial injury was the most common accompanying injury. Multipletrauma patients with chest injury had higher injury severity score (ISS) versus patients with isolated chest injury (P=0.003). Conclusions:Chest wall injuries and haemo/ pneumothorax comprise a considerable number of injuries in survival victims of earthquakes. Consequently, the majority of these patients can be treated with observation or tube thoracostomy. We should train and equip the health workers and members of rescue teams to treat and manage these patients in the field.     

Pattern of injuries due to wild animal attack among patients presenting to the emergency department: A retrospective observational study

PurposeThe human-wildlife conflicts (HWCs) causing nuisances and injuries are becoming a growing public health concern over recent years worldwide. We aimed to study the demographic profile, mode of injury, pattern of injury, and outcome of wild animal attack victims presented to the emergency department.MethodsThis retrospective cross-sectional study was conducted in the emergency department of a tertiary-care hospital in Eastern India. Data were retrieved from the medical records from May 2017 to May 2021. Patients of all ages and genders attacked by wild animals and secondary injuries were included in this study. Patients with incomplete data, injuries due to the attack of stray and domestic animals and trauma due to other causes were excluded. Demographic profile, mode of injury, the pattern of injury, injury severity score (ISS), radiological pattern, and outcome were recorded. Statistical analysis with R (version 3.6.1.) was conducted.ResultsA total of 411 wild animal attack victims were studied, of which 374 (90.9%) were snakebite injuries and 37 (9.1%) were wild mammalian (WM) attack injuries. The mean age of WM attack victims was 46 years, and the male-to-female ratio was 4:1. Elephant attack injury (40.5%) was the most common WM attack injury reported. Most WM attacks (43.2%) occurred between 4:00 a.m. to 8:00 a.m. The median ISS was 18.5 (13–28), where 54.2% of patients had polytrauma (ISS>15). Elephant attack was associated with a higher ISS, but the difference was not significant compared to other animal types (p = 0.2). Blunt trauma was common pattern of injury in the elephant attack injury cases. Lacerations and soft tissue injuries were common patterns in other animal attacks. Among snakebites, neurotoxic was the most common type (55.4%), and lower extremity was the most common site involved.ConclusionThe young male population is the major victim of HWCs; and elephant is the most common animal involved. There is a need to design scientifically sound preventive strategies for HWCs and to strengthen the preparedness in health establishments to manage victims effectively.     

Dismounted complex blast injuries: patterns of injuries and resource utilization associated with the multiple extremity amputee

The objective of this report is to analyze the resource utilization and injury patterns of complex dismounted blast injuries. A retrospective review of U.S. service members injured in combat between 2007 and 2010 was conducted. Data analyzed included age, injury mechanism, amputated limbs, number and type of associated injuries, blood products utilized, intensive care unit length of stay (ILOS), hospital length of stay (HLOS) and the Injury Severity Score (ISS). Patients were stratified based on the number of amputations. Sixty-three patients comprised the multiple extremity amputation (MEA) group. Ninety-eight percent sustained injuries from an improvised explosive device (IED) and 96% were dismounted. The ISS, number of surgical encounters, blood products utilized and ILOS were all clinically significantly different than controls. Care of multiple extremity amputees involves the utilization of significant resources. This knowledge may better help surgeons and administrators allocate assets at hospitals, both military and civilian, who care for this complex and challenging patient population.     

Factors Influencing Geriatric Orthopaedic Trauma Mortality

IntroductionThis study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation.MethodsA retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability.Results174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival.ConclusionsAn ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.     

Children in side-impact motor vehicle crashes: seating positions and injury mechanisms

BACKGROUND: This study aimed to describe the injury mechanisms of children involved in side-impact car crashes, particularly as these relate to seating position, and to estimate the danger of the near-side seating position. METHODS: A prospective two-center study of children involved in severe car crashes in Canada was conducted as well as a retrospective cohort study of children involved in crashes reported in the Fatality Analysis Reporting System (FARS) and the National Automotive Sampling System: Crashworthiness Data System (NASS CDS). RESULTS: Children sitting at the side the car was struck (near-side position) sustained severe head, trunk, and limb injuries. Many of these injuries were attributable to direct intrusion, but some occurred without direct damage to the occupant compartment. Center-seat and far-side occupants had severe injuries only when unrestrained. Injury severity scores were higher for children seated on the near side, and this was statistically significant (p = 0.024) The analysis of Fatality Analysis Reporting System data showed that the risk of fatality was higher for children seated in the near-side position than for those in the center-seat position. The fatality risk ratio was 2.53 (95% confidence interval [CI], 2.08-3.07) for restrained children and 1.84 (95% CI, 1.57-2.17) for unrestrained children. Analysis of the NASS-CDS data showed that for restrained children, severe injury (ISS > or = 16) was more common among those on the near side (7 per 1,000 children) than among those in the center seat (2 per 1,000) or on the far-side seat (1 per 1,000) (p < 0.001). CONCLUSIONS: Severe injuries to near-side occupants occurred in both the presence and absence of compartment intrusion. A typical pattern of head, chest, and extremity injury similar to that seen among child pedestrians was observed among near-side child occupants in side-impact crashes. The center seat was statistically safer than the near-side seat, particularly for restrained child occupants. Scene information may be useful to trauma teams for the prediction of injury type and location. Avoiding intrusion and preventing the occupant from striking the vehicle wall are both important to side-impact protection for children. Improvement of the vehicle safety cage may protect against intrusion injuries. Seating two child occupants in inboard seating positions may provide additional protection against intrusion injuries, and also may protect against nonintrusion injuries.     

The increasing incidence of severe pelvic injury in motor vehicle collisions

BACKGROUND: Pelvic fractures constitute a major cause of death and residual disability in motor vehicle collisions (MVC). To date there has been poor documentation of the epidemiology of severe pelvic injuries. A detailed retrospective examination of all abbreviated injury score (AIS) > or = 4 pelvic fractures sustained in occupants of MVCs seen at this lead trauma hospital over the last 12 years and in the province of Ontario over the last 6 years was completed. METHODS: The regional trauma centre registry and provincial database were used to obtain demographics, injuries, course in hospital and crash data on patients sustaining AIS > or = 4 pelvic injuries between May 1988 and April 2000. Data was analysed for drivers (D), front (FP) and rear (RP) passengers in 4-year blocks. Means (S.D.) with t-test for continuous and chi2 for categorical data were used for analysis. RESULTS: AIS > or = 4 pelvic fractures increased significantly in D and FP over 12 years and in RP over the last 8 years. Similar significant increases were seen throughout the province over the last 6 years. No significant change in age, sex, ISS or referral patterns was seen. Lateral impact collisions also increased over the study duration. Occupants with pelvic injury compared to all MVC survivors ISS > or = 16 during the same study period had a higher ISS (P < 0.001), utilised more blood in 24h and in total (P < 0.001) and died more frequently (P < 0.001). However, significantly fewer required ICU support (P < 0.01) which may reflect the associated injuries. Patients with pelvic fractures had significantly fewer head and chest injuries as well as fewer face and neck injuries. They did have significantly more injuries in the region of the pelvis including lumbar and sacral spine fractures, genitourinary, liver, spleen and lower extremity blood vessel, nerve and bone injuries. CONCLUSION: This study documented an increasing incidence of severe pelvic injury resulting from MVCs. This may be related to an associated increase in the incidence of lateral impact collisions. The role of side impact protection and side airbags, introduced to decrease injury severity in lateral impact collisions will require further study.     

Facilitators and barriers of using digital technology for the management of diabetic foot ulcers: A qualitative systematic review

The use of digital technology has been shown to be effective in managing chronic conditions. Telemedicine and mobile application are two common applications of digital technology in managing diabetic foot ulcers (DFU). The facilitators and barriers of using it for DFU management are yet to be explored. This is a qualitative systematic review. Five bibliography databases and grey literature sources were searched (2000‐2019). Two reviewers independently screened the citations, extracted the data, assessed the quality of the included studies, and performed thematic synthesis. Three studies on patients and five studies on healthcare practitioners (HCPs) were included. Two studies focused on the use of mobile applications and six on telemedicine. In studies on patients, four analytical themes were generated: the relationships with HCPs; the attitude towards the usage of digital technology; the role of wound image taking; and impact of digital technology on DFU care, encompassing 15 facilitators (eg, enabling community support, improving wound care knowledge) and 12 barriers (eg, lack of technological savviness, difficulty reading on smartphones). Three analytical themes were generated from studies on HCPs: the impact of digital technology on HCPs; the role of digital technology in DFU care; and organisation of DFU care delivery, encompassing 17 facilitators (eg, adequate wound care training, digital technology enables holistic care) and 16 barriers (eg, lack of multidisciplinary approach in caring for DFU, lack of direct contact in care provision). Patients and HCPs reported various barriers and facilitators relating to different aspects of using digital technology in DFU management. Our findings can help inform future research as well as the adoption of digital technology in DFU management.     

Variation in treatment of pediatric spleen injury at trauma centers versus nontrauma centers: a call for dissemination of American Pediatric Surgical Association benchmarks and guidelines

BACKGROUND: American Pediatric Surgical Association consensus guidelines for children with blunt spleen injuries have been defined and validated in children's hospitals, but large administrative data sets indicate that only 10% to 15% of children with blunt spleen injuries are treated at children's hospitals. We sought to identify the frequency and compare the treatment of children with spleen injury in hospitals with and without recognized trauma expertise, with the aim of identifying a meaningful target for dissemination of benchmarks and consensus guidelines. STUDY DESIGN: State health departments' administrative data sets from California, Florida, New Jersey, and New York were analyzed for 2000, 2001, and 2002. All children with head injury or other nonspleen abdominal injuries requiring surgery were excluded. Injury Severity Scores were determined by ICDMAP-90. RESULTS: There were 3,232 patients with blunt spleen injury. Trauma centers had a significantly lower rate of operation for both multiply injured patients (15.3% versus 19.3%, p < 0.001) and those with isolated injury (9.2% versus 18.5%, p < 0.0001) when compared with nontrauma centers. The operative rates at both trauma centers and nontrauma centers exceed published American Pediatric Surgical Association benchmarks for all children with spleen injury (5% to 11%) and the subset with isolated spleen injury (0% to 3%). Independent risk factors for splenectomy included ages 15 to 19 years (p < 0.002), spleen injury severity (p < 0.0001), and presence of multiple injuries (p < 0.04). Adjusted odds ratio for risk of splenic operation in all patients with spleen injury was 2.122 (95% CI:1.455- 3.096) when treated at a nontrauma center (p < 0.0001). CONCLUSIONS: These multistate discharge data indicate that treatment of children with blunt spleen injury differs significantly when comparing trauma centers and nontrauma centers. Because nearly two-thirds of these children were treated at trauma centers, dissemination of American Pediatric Surgical Association guidelines and benchmarks through state or regional trauma systems may reduce the number of children having operations for splenic injury.