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Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.Treatment study.III.

To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations.International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949, these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements, and outcomes of civilian trauma in combat zones has not been previously characterized.Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005 to 2019. Inclusion criteria were civilians and Non-North Atlantic Treaty Organization (NATO) Coalition Personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized.A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age above 13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median Injury Severity Score (ISS) was 9 in each cohort with ISS≥25 in 2236 (13.4%) civilians and 1398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5850 civilians received a transfusion with 2118 (12.6%) of them receiving ≥10 units; 4590 NNCPs received a transfusion with 1669 (12.6%) receiving ≥10 units. MTF mortality rates were civilians 1263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and nonoperative, were similar between both groups.In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as NNCP. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.

The 2022 war in Ukraine has highlighted the unacceptable consequences wrought on civilians and health infrastructure by conflict. Children are among the most vulnerable of those affected and constitute an increasing percentage of non-combatants injured in conflicts globally. A disproportionate number of these injuries are caused by blast mechanisms from munitions including ‘conventional’ landmines and indiscriminate explosive weapons such as barrel bombs and improvised explosive devices. In 21st century conflict, children are no longer only accidental casualties of war, but are increasingly targeted by parties through acts such as bombing of school buses and playgrounds, conscription as child soldiers, and use as human shields. In the present viewpoint article, we review the state of pediatric blast injury studies, synthesizing current understandings of injury epidemiology and identifying gaps in research to advance the field towards a concrete agenda to improve care for this vulnerable population.

Background The World Health Organization (WHO) Trauma Care Checklist (TCC) has been documented to improve care of the injured. Factors that promote TCC use have not been well evaluated. We sought to identify barriers and facilitators affecting TCC use. Methods A qualitative study was conducted by interviewing regional leaders and health care providers at hospitals where the initial WHO TCC pilot study had been conducted in 2010–2012. Study participants included trauma system directors, surgeons, emergency medicine physicians, nurses, and house staff in nine countries. Interview transcripts were thematically analyzed in Dedoose software using deductive and inductive coding strategies incorporating elements of grounded theory. Results Eighteen participants representing nine of the 11 original pilot sites were interviewed, including 14 doctors and four nurses. Participants represented departments of trauma/trauma surgery (n = 13) and emergency medicine (n = 5). Three sites continued to use the TCC in a nearly original form; three sites used a significantly modified version; and the remaining three sites no longer used it. The most commonly identified facilitator of TCC use was endorsement at both the front-line provider and institutional/leadership level (n = 7). Personnel-related issues and resistance from individual providers were the most commonly identified barriers (n = 10). Conclusion Presence of an institutional champion, context-specific adaptation, and integration of the TCC with existing care and documentation practices contribute to successful utilization. Personnel constraints such as revolving trainees and resistance from individual providers hinder utilization. To improve TCC uptake, participants also recommended that TCC be more closely integrated with courses such as Advanced Trauma Life Support.

Background Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. Methods We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. Results The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. Conclusions Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements. Electronic supplementary material The online version of this article (10.1007/s00268-020-05428-y) contains supplementary material, which is available to authorized users.

Importance Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.