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PURPOSE: To determine if household composition is an independent risk factor for fatal unintentional injuries related to child maltreatment. DESIGN: A population-based, case-control study using data from the Missouri Child Fatality Review Program for 1992-1999. METHODS: Children under age five who died during the 8-year study period were eligible for study. Cases were defined as children who died of an unintentional injury that occurred when a parent or other adult caregiver: (a) was not present, (b) was present but not capable of protecting the child, (c) placed the child in an unsafe sleep environment, or (d) failed to use legally mandated safety devices. Controls were randomly selected from children who died of natural causes. Household composition was classified based on relationship of the adults living in the household to the deceased child. The five household composition categories were households with: (a) two biologic parents and no other adults, (b) one biologic parent and no other adults, (c) one or two biologic parents and another adult relative, (d) stepparents or foster parents, and (e) one or two biologic parents and another unrelated adult. Logistic regression analyses were conducted and odds ratios estimating the risk of maltreatment-related unintentional death associated with each household category compared to the reference households: those with two biologic parents and no other adults. FINDINGS: Three hundred eighty children met the case definition. Children residing within households with adults unrelated to them had nearly six times the risk of dying of maltreatment-related unintentional injury (adjusted odds ratio [aOR] 5.9; 95% confidence interval [95% CI] 1.9-17.6). Children residing with step or foster parents and those living with other, related adults were also at increased risk of maltreatment death (aOR 2.6, 95% CI 1.0-6.5; and aOR 2.1, 95% CI 1.0-4.5, respectively). Risk was not elevated for children in households with a single biologic parent and no other adults in residence. CONCLUSIONS: Young children residing in households with unrelated adults, step-parents, or foster parents are at increased risk of fatal unintentional injury related to maltreatment. Nurses can use the findings of this study to facilitate injury prevention by identifying families at risk for fatal unintentional injuries and providing these families with targeted education or referral. [ABSTRACT FROM AUTHOR]

The authors describe the growth from 1987 through 1996 of the Occupational Pesticide Poisoning Surveillance Program at the Texas Department of Health. The program was initially based on a Sentinel Event Notification System for Occupational Risks (SENSOR) model, using sentinel providers to report cases, supplementing the passive reporting by physicians that was required by law. The model was evaluated after five years, and significant changes were implemented to improve case ascertainment. Current active surveillance methods emphasize collaboration with a number of agencies and organizations for identification of cases and follow-up. The number of confirmed occupational cases increased from 9 workers in 1987 to 99 workers in 1996. The evolution from a passive system to an active surveillance program expanded the number of reported cases and strengthened inter-agency collaborations. [ABSTRACT FROM AUTHOR]

This review summarizes the descriptive epidemiology of injuries among women in the United States, highlighting major problems as well as needs and opportunities for intervention and research. Injury mortality rates for 1984-88 were calculated from the National Center for Health Statistics mortality data tapes. Additional injury mortality and all injury morbidity information were derived from existing literature. Studies providing gender-specific U.S. injury information during the last ten years were reviewed. Injuries are the leading causes of death for females to age 34 and are responsible for more years of potential life lost than any other cause of death. The lifetime cost of injuries to females is approximately 50 billion dollars annually. Motor vehicle related injuries, falls, and violence are the most significant injury problems for women. Although morbidity is far greater than mortality, access to information about nonfatal injuries is extremely limited. What evidence does exist points to the importance of domestic assault as a major, underrecognized source of preventable injury. Though the greater magnitude of injury among men frequently eclipses the significance of injury as a problem for women, this paper presents evidence that injury is a problem which should feature prominently in the women's health agenda for the nation. There are pressing research needs to understand the changing trends in injuries to females and to identify appropriate intervention strategies. In addition, the study points to the needs for improvement in data systems to document injury morbidity. [ABSTRACT FROM AUTHOR]

Data on occupational injury fatalities in Alaska for the period 1980-85 were compiled from workers' compensation claims and death certificates. These data yielded 422 unique cases for the 6-year period, for an average annual fatality rate of 36.3 per 100,000 workers. This rate is 5 times higher than the Bureau of Labor Statistics estimate of 7.6 per 100,000 for the United States during the same period. The four industries with the highest fatality rates were the same for Alaska as for the nation (agriculture-forestry-fishing, construction, mining, and transportation-communication-public utilites). The leading causes of occupational fatalities in Alaska, however, were considerably different than for the United States as a whole. Nationally, motor vehicles and industrial equipment accidents are the leading causes of death. In Alaska, the leading causes of occupational injury mortality are aircraft crashes and drowning. These findings highlight the benefit of local surveillance in planning prevention strategies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the role of household composition as an independent risk factor for fatal inflicted injuries among young children and describe perpetrator characteristics. DESIGN, SETTING, AND POPULATION: A population-based, case-control study of all children < 5 years of age who died in Missouri between January 1, 1992, and December 31, 1999. Missouri Child Fatality Review Program data were analyzed. Cases all involved children with injuries inflicted by a parent or caregiver. Two age-matched controls per case child were selected randomly from children who died of natural causes. MAIN OUTCOME MEASURE: Inflicted-injury death. Household composition of case and control children was compared by using multivariate logistic regression. We hypothesized that children residing in households with adults unrelated to them are at higher risk of inflicted-injury death than children residing in households with 2 biological parents. RESULTS: We identified 149 inflicted-injury deaths in our population during the 8-year study period. Children residing in households with unrelated adults were nearly 50 times as likely to die of inflicted injuries than children residing with 2 biological parents (adjusted odds ratio: 47.6; 95% confidence interval: 10.4-218). Children in households with a single parent and no other adults in residence had no increased risk of inflicted-injury death (adjusted odds ratio: 0.9; 95% confidence interval: 0.6-1.9). Perpetrators were identified in 132 (88.6%) of the cases. The majority of known perpetrators were male (71.2%), and most were the child's father (34.9%) or the boyfriend of the child's mother (24.2%). In households with unrelated adults, most perpetrators (83.9%) were the unrelated adult household member, and only 2 (6.5%) perpetrators were the biological parent of the child. CONCLUSIONS: Young children who reside in households with unrelated adults are at exceptionally high risk for inflicted-injury death. Most perpetrators are male, and most are residents of the decedent child's household at the time of injury. [ABSTRACT FROM AUTHOR]

Objectives: This study describes characteristics of children ages 1 to 17 years who died of coronavirus disease 2019 (COVID-19) in 2020 to 2022 and whose deaths were reviewed by child death review (CDR) teams across the United States., Methods: We used data in the National Fatality Review-Case Reporting System to examine children who died of COVID-19. Deaths were determined because of COVID-19 from death certificates or CDR determinations., Results: A total of 183 children 1 to 17 years old who died of COVID-19 were reported in the National Fatality Review-Case Reporting System. One-third (33%) were 15- to 17-year-olds, and 26% were 1- to 4-year-olds. Fifty-six percent were reported as male, 54% white, 24% Black, and 18% Hispanic ethnicity. Physicians declared cause of death in at least 82% of deaths. More than two-thirds (68%) had a medical condition (excluding COVID-19) at time of death. The most common conditions were nervous system disorders (19%), congenital disorders (14%), obesity (12%), respiratory disorders (12%), and neurodevelopmental disorders (10%). Of children with an underlying condition, 35% had 3 or more conditions. Less than half (42%) had contact with a health care provider within a month of their death; and three-fourths died within 14 days of exposure., Conclusions: This study describes the demographics, death investigation findings, and medical conditions of children who died of COVID-19. The results highlight the short timeline between COVID-19 exposure and death. Pandemic planning that prioritizes prevention efforts and timely access to effective medical care may result in saving children's lives., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: Develop guidelines for child death review teams that will improve the consistency in classifying child maltreatment (CM) and distinguish between classification of exposure to hazards and neglect for sleep-related sudden unexpected infant deaths (SUID)., Methods: Sleep-related SUID (n = 25 797) were identified from the National Fatality Review-Case Reporting System between 2004 and 2018. Key variables considered when classifying CM among sleep-related SUID were identified. Logistic regression was used to assess the strength of associations and identify factors that distinguished between exposure to hazards and neglect. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Guidelines were developed based on these findings., Results: Among the 13 034 sleep-related SUID with CM identified, hazards in the infant sleep environment were strongly associated with classification of both exposure to hazards and neglect, as were supervisor impairment and child welfare substantiation of the death. Comparing neglect to exposure to hazards, there was no association with sleep environment hazards with ORs ranging from 0.8 to 1.3 (95% CI 0.4-3.0), but sleep-related SUID were approximately twice as likely to be classified as neglect when the supervisor was impaired (OR 2.3, 95% CI 2.0-2.7) or child welfare action was taken (OR 1.8, 95% CI 1.5-2.0). The guidelines recommend classification of exposure to hazards for sleep environment hazards with elevation to neglect if the supervisor was impaired or child welfare substantiated the death., Conclusions: Among sleep-related SUID, classification of exposure to hazards is based on presence of sleep environment hazards, whereas neglect is based on supervisor impairment and child welfare action., Competing Interests: CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose., (Copyright © 2024 by the American Academy of Pediatrics.)

Objectives: To explore the National Fatality Review Case Reporting System (NFR-CRS) as a new data source to (1) characterize pediatric vehicular heatstroke (PVH) deaths among children <15 years of age reviewed by Child Death Review teams, and (2) identify factors independently associated with common PVH scenarios and incident locations., Methods: Data for 2005-2019 were used to characterize 296 PVH deaths. Frequencies and percentages were calculated to describe child, supervisor, and incident characteristics. Multiple logistic regression with and without imputation were carried out to identify factors associated with the two outcomes of interest: PVH scenario (left in vehicle vs. gained access) and incident place (supervisor workplace vs. other locations). Odds ratios and 95% confidence intervals (OR, 95% CI) were calculated., Results: Most children had been left unattended in vehicles ( N  = 225, 76.0%) and 13.5% ( N  = 40) had gained access independently. Children were most often male ( N  = 168, 56.8%), non-Hispanic White ( N  = 131, 44.3%), and <2 years of age ( N  = 172, 58.1%). Disability or chronic illness was noted for 4.7% ( N  = 14), 13.9% ( N  = 41) had a history of maltreatment, and 6.1% ( N  = 18) an open CPS case at the time of incident. Children left unattended were more likely to be <2 years of age (adjusted imputed OR 26.7, CI 7.3-97.2) and less likely to have an open CPS case (0.2, 0.0-0.4) and for the incident to occur at home (0.2, 0.1-0.9) compared to children who gained access. PVH deaths occurring at the supervisor's workplace were more likely to be <2 years of age (6.2, 2.4-15.8), to have occurred on a weekday (5.9, 1.7-20.9), and to have been supervised by their parent at the incident time (2.7, 1.1-6.7) compared to other locations., Conclusions: The results align with previous PVH findings and added new information on child race/ethnicity, CPS action, disability/chronic illness, and maltreatment. With the exception of parents being more likely to be the supervisor in incidents occurring at home, which was expected, neither supervisor characteristics nor child race/ethnicity or sex were independently significant in multiple regression, suggesting that PVH is pervasive and that education campaigns should be similarly broad.

We sought to compare risk factors contributing to unintentional, homicide, and suicide firearm deaths in children. We conducted a retrospective review of the National Fatality Review Case Reporting System. We included all firearm deaths among children aged 0-18 years occurring from 2007 to 2016. Descriptive analyses were performed on demographic, psychosocial, and firearm characteristics and their relationship to unintentional, homicide, and suicide deaths. Regression analyses were used to compare factors contributing to unintentional vs. intentional deaths. There were 6148 firearm deaths during the study period. The mean age was 14 years (SD ± 4 years), of which 81% were male and 41% were non-Hispanic White. The most common manners of death were homicide (57%), suicide (36%), and unintentional (7%). Over one-third of firearms were stored unlocked. Homicide deaths had a higher likelihood of occurring outside of the home setting (aOR 3.2, 95% CI 2.4-4.4) compared with unintentional deaths. Suicide deaths had a higher likelihood of occurring in homes with firearms that were stored locked (aOR 4.2, 95% CI 2.1-8.9) compared with unintentional deaths. Each manner of firearm death presents a unique set of psychosocial circumstances and challenges for preventive strategies. Unsafe firearm storage practices remain a central theme in contributing to the increased risk of youth firearm deaths.

Background and Objectives: Suicide is a leading cause of death among youth in the United States. The coronavirus disease 2019 (COVID-19) pandemic raised concerns that suicide rates will increase. The National Fatality Review-Case Reporting System documents circumstances of child deaths reviewed by multidisciplinary teams. In April 2021, a question asking whether COVID-19 directly or indirectly impacted the child's death was added to the National Fatality Review-Case Reporting System. The objective of this study was to identify factors related to suicide deaths among youth during the COVID-19 pandemic., Methods: This exploratory study of youth aged 10 to 17 years occurring during 2020 to 2021 compared demographic and incident characteristics, life stressors, social/mental health histories, and pandemic-related disruptions to school, health, and mental health for COVID-19-impacted suicides and non-COVID-19-impacted suicides using descriptive statistics. χ2 statistics assessed statistical significance in differences across the 2 groups., Results: A total of 552 suicides were included for study. Higher proportions of COVID-19-impacted suicides (n = 144) were by hanging (51% vs 40%) and occurred in suburban areas (57% vs 45%) compared with non-COVID-19-impacted suicides (n = 408). COVID-19-impacted youth also experienced significantly more isolation (60% vs 14%), school problems (42% vs 19%), depression (43% vs 24%), and/or anxiety disorder (23% vs 12%) diagnoses., Conclusions: A subset of youth experienced significant effects of the pandemic and associated measures implemented to mitigate the spread of COVID-19. They were proportionally more likely to experience isolation, school and mental health care disruptions, behavior changes, and severe emotional distress; all signs of increased risk for suicide., (Copyright © 2023 by the American Academy of Pediatrics.)

Background: While risk factors have been identified among infants and young children, less is known about child maltreatment fatalities among older children., Objectives: To describe the social and demographic characteristics of children where abuse or neglect was determined to cause or contribute to their death, compare characteristics and circumstances of the deaths by cause and manner of death and type of maltreatment, and explore the role of abuse and neglect in child suicides., Participants and Setting: Secondary analysis of deaths due to child abuse or neglect among children ages 5-17 years old occurring during 2009-2018 and documented in the National Fatality Review-Case Reporting System., Methods: Child, family, and social characteristics were compared by child age (5-10 years vs. 11-17 year-olds), and by cause and manner of death. Frequencies and proportions were reported and compared using chi-square statistics., Results: 1478 maltreatment-related deaths were identified. Higher proportions of older children were non-Hispanic white, had a history of chronic disease or disability, had problems in school, and had a history of mental health issues. Forty-three percent of the maltreatment deaths were due to homicide and 10 % by suicide. Higher proportions (65 %) of younger children (5-10 years old) died by homicide, compared to older children (35 % among ages 11-17y). While 58 % of deaths overall were related to neglect, 68 % of deaths in older children were related to neglect, including 80 % of suicides., Conclusions: The causes of child maltreatment deaths among children 5-17y vary by age. Child neglect caused and/or contributed to most child suicides., Competing Interests: Declaration of competing interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Introduction: This study seeks to describe the circumstances of fire deaths among children, identify deaths related to fireplay, and compare children whose deaths were related to fireplay with non-fireplay-related deaths., Methods: Children aged 1-14 years who died in a fire during 2004-2016 were identified from the National Fatality Review Case Reporting System. Social, demographic, and fire characteristics were described and then compared for children who died in fires caused by fireplay versus non-fireplay-related deaths. Unadjusted ORs and 95% CIs were calculated. Data were collected 2004-2018 and analyzed in 2019., Results: A total of 1,479 children who died in fires were identified. They were predominantly male (54%) and White (47%); 34% were Black. Two or more children died in 54% of incidents. Fires occurred most frequently in single-family homes (52%) and rental properties (37%); 23% were started by smoking materials or candles. Smoke alarm information was largely missing (42%) and noted to be present and working for only 82 deaths. Fireplay was responsible for 175 (12%) of the deaths. Compared with non-fireplay-related deaths, children who died in fireplay fires were more likely to be aged 1-4 years (OR=2.6, 95% CI=1.5, 4.3), male (OR=1.6, 95% CI=1.2, 2.2), have supervision documented as no, but needed (OR=8.8, 95% CI=4.1, 18.8), and have an open Child Protective Services case (OR=1.8, 95% CI=1.1, 3.0)., Conclusions: This study provides data on supervision and the role of fireplay in fatal fires among young children, offering information for the development of innovative primary prevention strategies and future research., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Suicide is a leading cause of death among children in the United States; firearms cause 37% of these deaths. Research is needed to better understand firearm accessibility among youth at risk for suicide. We reviewed data from the National Fatality Review Case Reporting System (NFR-CRS). Firearm suicide deaths of children ages 10-18 occurring 2004 through 2015 with completed suicide-specific section were included. Children who had talked about, threatened or attempted suicide were identified as "Greater Risk" (GR). Odds ratios (OR) and 95% confidence intervals (95%CI) were calculated. Of the 2106 firearm suicide deaths, 1388 (66%) had a completed NFR-CRS suicide section. Of these, 36% (494/1388) met the criteria for GR. Firearms were less likely to be stored in a locked location for GR children [adjusted OR 0.62, (95%CI 0.49-0.98)]. Strategies to limit firearm access, particularly for GR youth, should be a focus of suicide prevention efforts.

Background: Child maltreatment is a major public health problem, but population-based surveillance and research is hindered by limitations of official child welfare data. The present study used a promising complementary data source, hospital discharge data, to investigate risk factors for infant injuries suggestive of maltreatment., Methods: Discharge data from all hospital births to New York City residents from 1995 to 2004 were linked to birth certificates and to subsequent infant hospitalizations within 12 months after delivery. Probable maltreatment of infants was identified with 33 injury diagnosis codes highly correlated with maltreatment. Modified Poisson regression estimated the association of sociodemographic factors and pregnancy/birth characteristics with subsequent infant admission for probable maltreatment., Results: Risk factors for maltreatment included neonatal intensive care unit stays of more than 11 days (adjusted risk ratio [aRR] = 1.8; 95% confidence interval [CI]: 1.1-2.8), preterm birth (aRR = 1.6; 95% CI: 1.2-2.1), maternal age less than 20 years (aRR = 1.5; 95% CI: 1.2-1.9), and public insurance (aRR = 1.5; 95% CI: 1.2-1.9). Factors associated with reduced maltreatment risk included mother born outside the United States (aRR = 0.7; 95% CI: 0.6-0.8) and female infant (aRR = 0.7; 95% CI: 0.6-0.9)., Conclusions: Sociodemographic factors and challenges at birth (preterm, neonatal intensive care unit stays) are important risk factors for subsequent maltreatment-related hospitalization, with potential implications for prevention targeting., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Health informatics projects combining statewide birth populations with child welfare records have emerged as a valuable approach to conducting longitudinal research of child maltreatment. The potential bias resulting from linkage misspecification, partial cohort follow-up, and outcome misclassification in these studies has been largely unexplored. This study integrated epidemiological survey and novel administrative data sources to establish the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project. Using these data we evaluated and quantified the impact of non-linkage misspecification and single source maltreatment ascertainment use on reported maltreatment risk and effect estimates., Methods: The ALCANLink project integrates the 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) sample with multiple administrative databases through 2014, including one novel administrative source to track out-of-state emigration. For this project we limited our analysis to the 2009 PRAMS sample. We report on the impact of linkage quality, cohort follow-up, and multisource outcome ascertainment on the incidence proportion of reported maltreatment before age 6 and hazard ratios of selected characteristics that are often available in birth cohort linkage studies of maltreatment., Results: Failure to account for out-of-state emigration biased the incidence proportion by 12% (from 28.3% w to 25.2% w ), and the hazard ratio (HR) by as much as 33% for some risk factors. Overly restrictive linkage parameters biased the incidence proportion downwards by 43% and the HR by as much as 27% for some factors. Multi-source linkages, on the other hand, were of little benefit for improving reported maltreatment ascertainment., Conclusion: Using the ALCANLink data which included a novel administrative data source, we were able to observe and quantify bias to both the incidence proportion and HR in a birth cohort linkage study of reported child maltreatment. Failure to account for out-of-state emigration and low-quality linkage methods may induce bias in longitudinal data linkage studies of child maltreatment which other researchers should be aware of. In this study multi-agency linkage did not lead to substantial increased detection of reported maltreatment. The ALCANLink methodology may be a practical approach for other states interested in developing longitudinal birth cohort linkage studies of maltreatment that requires limited resources to implement, provides comprehensive data elements, and can facilitate comparability between studies.

Accurate estimation of the incidence of maltreatment-related child mortality depends on reliable child fatality review. We examined the inter-rater reliability of maltreatment designation for two Alaskan Child Death Review (CDR) panels. Two different multidisciplinary CDR panels each reviewed a series of 101 infant and child deaths (ages 0-4 years) in Alaska. Both panels independently reviewed identical medical, autopsy, law enforcement, child welfare, and administrative records for each death utilizing the same maltreatment criteria. Percent agreement for maltreatment was 64.7% with a weighted Kappa of 0.61 (95% CI 0.51, 0.70). Across maltreatment subtypes, agreement was highest for abuse (69.3%) and lowest for negligence (60.4%). Discordance was higher if the mother was unmarried or a smoker, if residence was rural, or if there was a family history of child protective services report(s). Incidence estimates did not depend on which panel's data were used. There is substantial room for improvement in the reliability of CDR panel assessment of maltreatment related mortality. Standardized decision guidance for CDR panels may improve the reliability of their data., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Assess the association between caregiver supervision and acute unintentional injury in young children; evaluate whether lower levels of supervision result in more severe injury., Methods: A case cross-over study was conducted. Parents of children aged ≤4 years whose injuries required emergency department (ED sample) treatment or admission to the hospital (inpatient sample) were interviewed. Information on supervision (3 dimensions: proximity, attention, continuity) at the time of injury and 1 h before the injury (control time) was collected. An overall supervision score was created; a higher score indicates closer supervision. Hospital admission served as a proxy for injury severity. ORs and 95% CIs were calculated., Results: Interviews were completed by 222 participants; 50 (23%) were in the inpatient sample. For each supervision dimension the inpatient sample had higher odds of injury, indicating effect modification requiring separate analyses for inpatient and ED samples. For both samples, proximity 'beyond reach' was associated with the highest odds of injury; compared with 1 h before injury, children were more likely to be beyond reach of their caregiver at the time of injury (inpatient sample: OR 11.5, 95% CI 2.7 to 48.8; ED sample: OR 2.9, 95% CI 1.8 to 4.9). Children with lower supervision scores had the greatest odds of injury (inpatient sample: OR 8.0, 95% CI 2.4 to 26.6; ED sample: OR 3.3, 95% CI 1.9 to 5.6)., Conclusions: Lower levels of adult supervision are associated with higher odds of more severe injury in young children. Proximity is the most important supervision dimension for reducing injury risk., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Fatal child maltreatment is a compelling problem in the United States. National estimates of fatal child maltreatment, based largely on child welfare data, have fluctuated around 1,500 deaths annually for the past ten years. However, the limitations of child welfare and other mortality data to accurately enumerate fatal child maltreatment are well documented. As a result of these limitations, the true magnitude of fatal child maltreatment remains unknown. Public health surveillance has been proposed as a mechanism to improve estimation of fatal child maltreatment, as well as to collect and analyze relevant risk factor data for the ultimate goal of developing prevention strategies. This paper describes public health surveillance efforts undertaken to improve estimation of fatal child maltreatment, and presents the unique challenges of identifying fatal child neglect. The strengths and limitations of existing sources of child maltreatment fatality data are reviewed and broad recommendations for strategies to advance public health surveillance of fatal child maltreatment are presented.

Objectives: We sought to describe the characteristics and sleep circumstances of infants who die suddenly and unexpectedly and to examine similarities and differences in risk factors among infants whose deaths are classified as resulting from sudden infant death syndrome (SIDS), suffocation, or undetermined causes., Methods: We used 2005 to 2008 data from 9 US states to assess 3136 sleep-related sudden unexpected infant deaths (SUIDs)., Results: Only 25% of infants were sleeping in a crib or on their back when found; 70% were on a surface not intended for infant sleep (e.g., adult bed). Importantly, 64% of infants were sharing a sleep surface, and almost half of these infants were sleeping with an adult. Infants whose deaths were classified as suffocation or undetermined cause were significantly more likely than were infants whose deaths were classified as SIDS to be found on a surface not intended for infant sleep and to be sharing that sleep surface., Conclusions: We identified modifiable sleep environment risk factors in a large proportion of the SUIDs assessed in this study. Our results make an important contribution to the mounting evidence that sleep environment hazards contribute to SUIDs.

Context: Reducing the number of largely preventable and tragic deaths due to child maltreatment (CM) requires an understanding of the magnitude of and risk factors for fatal CM and targeted research, policy, and prevention efforts. Public health surveillance offers an opportunity to improve our understanding of the problem of CM. In 2006, the Centers for Disease Control and Prevention (CDC) funded state public health agencies in California, Michigan, and Oregon to implement a model approach for routine and sustainable CM surveillance and evaluated the experience of those efforts., Objective: We describe the experiences of 3 state health agencies in building collaborations and partnerships with multiple stakeholders for CM surveillance., Design: Qualitative, structured key informant interviews were carried out during site visits as part of an evaluation of a CDC-funded project to implement a model approach to CM surveillance., Participants: Key informants included system stakeholders from state health agencies, law enforcement, child protective services, the medical community, and child welfare advocacy groups in the 3 funded states., Results: Factors that facilitated stakeholder engagement for CM surveillance included the following: streamlining and coordinating the work of Child Death Review Teams (CDRTs); demonstrating the value of surveillance to non-public health partners; codifying relationships with participating agencies; and securing the commitment of decision-makers. Legislative mandates were helpful in bringing key stakeholders together, but it was not sufficient to ensure sustained engagement., Conclusions: The engagement process yielded multiple benefits for the stakeholders including a deeper appreciation of the complexity of defining CM; a greater understanding of risk factors for CM; and enhanced guidance for prevention and control efforts. States considering or currently undertaking CM surveillance can glean useful insights from the experiences of these 3 states and apply them to their own efforts to engage stakeholders.

Most unintentional injury deaths among young children result from inadequate supervision or failure by caregivers to protect the child from potential hazards. Determining whether inadequate supervision or failure to protect could be classified as child neglect is a component of child death review (CDR) in most states. However, establishing that an unintentional injury death was neglect related can be challenging as differing definitions, lack of standards regarding supervision, and changing norms make consensus difficult. The purpose of this study was to assess CDR team members' categorisation of the extent to which unintentional injury deaths were neglect related. CDR team members were surveyed and asked to classify 20 vignettes-presented in 10 pairs-that described the circumstances of unintentional injury deaths among children. Vignette pairs differed by an attribute that might affect classification, such as poverty or intent. Categories for classifying vignettes were: (1) caregiver not responsible/not neglect related; (2) some caregiver responsibility/somewhat neglect related; (3) caregiver responsible /definitely neglect related. CDR team members from five states (287) completed surveys. Respondents assigned the child's caregiver at least some responsibility for the death in 18 vignettes (90%). A majority of respondents classified the caregiver as definitely responsible for the child's death in eight vignettes (40%). This study documents attributes that influence CDR team members' decisions when assessing caregiver responsibility in unintentional injury deaths, including supervision, intent, failure to use safety devices, and a pattern of previous neglectful behaviour. The findings offer insight for incorporating injury prevention into CDR more effectively.

Objective: In order to be reimbursed for the care they provide, hospitals in the United States are required to use a standard system to code all discharge diagnoses: the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9). Although ICD-9 codes specific for child maltreatment exist, they do not identify all maltreatment-related hospital and emergency department discharges. To increase the usefulness of medical data for public health surveillance of child maltreatment, this project sought to identify ICD-9 codes that are suggestive of child maltreatment., Methods: After review of the literature and discussions with experts, injuries and conditions that should raise suspicion of child maltreatment (physical or sexual abuse or neglect) were identified and a list of corresponding ICD codes was compiled. Using a statewide electronic database of hospital discharges and emergency department (ED) visits for the year 2000, visits by children assigned these ICD codes were identified, a sample of visits was selected, and medical records were reviewed to assess the circumstances of the injury or illness that led to the visit. Based on information in the medical record, the injury or illness was classified as maltreatment-related, or not., Results: There were 3,684 visits selected for review. Of these, 2,826 records were reviewed and classified; 1,200 (43%) records met the criteria for being maltreatment-related, 1,419 (50%) contained adequate information indicating the injury/condition was not likely maltreatment-related, and 207 (7%) records did not contain enough information to classify. Sixty-eight ICD codes had >66% of visits classified as maltreatment-related, the a priori criteria for a code to be considered suggestive of maltreatment. Codes suggestive of maltreatment include specific fractures, burns, and injuries of undetermined intent, among others., Conclusion: Several ICD codes were found that, when used with age restrictions and other specific exclusion criteria, are suggestive of maltreatment. This information may increase the usefulness of hospital discharge data for public health surveillance of child maltreatment., Practice Implications: Use of these suggestive codes facilitates identifying conditions and injuries that are likely maltreatment-related in hospital discharge and ED visit data. When used in conjunction with ICD maltreatment-specific codes, these suggestive codes may enhance the use of medical data for monitoring child maltreatment trends., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To determine whether there is seasonal variation (by season and month of year) in homicides among young children., Study Design: Homicide deaths in children

Injuries are a leading cause of childhood morbidity and are also common manifestations of child maltreatment, especially among young children. In an effort to determine whether injury-related Emergency Department (ED) visits among children aged 0 to 4 years were associated with child maltreatment reports, we identified all children with at least one injury-related ED visit in Missouri during 2000. Data on these injured children were linked to Missouri Child Protective Services (CPS) child abuse and neglect reports for 2000 and 2001. There were 50,068 children with at least one injury-related ED visit. Using children with one injury-related ED visit as the reference category, we calculated the relative risk of having a CPS report (or a substantiated report) for children with two, three, and four or more ED visits before a CPS report (or substantiated report). Compared to children with one visit, children with two visits were more likely to have a CPS report (relative risk [RR] 1.9; 95% confidence interval [CI] 1.8-2.0) and a substantiated report (RR 2.5; 95% CI 2.1-2.9). For children with four or more visits, the relative risk of a report and substantiated report was 3.8 (95% CI 3.0-4.7) and 4.7 (95% CI 2.4-9.2), respectively. Children with two or more injury-related ED visits in 1 year are more likely to be reported for child maltreatment and to have a substantiated report.

Objectives: We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment., Methods: Three states--California, Michigan, and Rhode Island--used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined., Results: These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100,000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources., Conclusions: No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.

Injuries are the leading cause of death in children and teenagers in the United States. The leading causes of unintentional injury vary by age and include drowning, poisoning, suffocation, fires, burns, falls, and motor vehicle, bicycle, and pedestrian-related crashes. Most injuries are preventable by modifying the child's environment (e.g., use of stair gates) and having parents engage in safety practices (e.g., keeping matches or lighters out of reach of children). Effective injury prevention methods include the use of childproof caps on medications and household poisons, age-appropriate restraints in motor vehicles (i.e., car seats, booster seats, seat belts), bicycle helmets, and a four-sided fence with a locked gate around residential swimming pools.

Objectives: The International Classification of Disease (ICD) external cause of injury E-codes do not sufficiently identify injury circumstances amenable to prevention. The researchers developed an alternative classification system (B-codes) that incorporates behavioral and environmental factors, for use in childhood injury research, and compare the two coding systems in this paper., Methods: All fatal injuries among children less than age five that occurred between January 1, 1992, and December 31, 1994, were classified using both B-codes and E-codes., Results: E-codes identified the most common causes of injury death: homicide (24%), fires (21%), motor vehicle incidents (21%), drowning (10%), and suffocation (9%). The B-codes further revealed that homicides (51%) resulted from the child being shaken or struck by another person; many fires deaths (42%) resulted from children playing with matches or lighters; drownings (46%) usually occurred in natural bodies of water; and most suffocation deaths (68%) occurred in unsafe sleeping arrangements., Conclusions: B-codes identify additional information with specific relevance for prevention of childhood injuries.

Background: Public health surveillance was established for nonfatal child maltreatment in Missouri using two data sources. This paper describes the epidemiology of nonfatal child maltreatment using this surveillance system, and assesses the usefulness of combining medical data with child protective services (CPS) reports for child maltreatment surveillance., Methods: Child abuse and neglect reports for children aged <10 years for 2000 were obtained from the Missouri Division of Family Services (DFS) and linked to hospital discharge and emergency department (ED) data for 2000. Children were classified as maltreated if they had an International Classification of Disease (ICD) maltreatment code for a hospital or ED visit, or a substantiated report to DFS. Validity of the ICD maltreatment codes was assessed in a 10% random sample of the hospital/ED visits. Medical records were reviewed to determine the accuracy of the maltreatment code assigned. The data analyses reported here were conducted in 2002 and 2003., Results: In the linked data, 5657 children met the case definition of maltreatment, providing a nonfatal maltreatment rate of 7.4/1000 children. Rates were higher among children aged <1 year (8.4/1000), females (7.7/1000), African Americans (11.8/1000), and children residing in rural counties (8.7/1000). The hospital/ED data identified proportionately more children who were African American, urban, physically abused, or infants, and uniquely identified only 10% of the total cases. In the validation sample, maltreatment was documented in 110 (87%) of the 127 records reviewed., Conclusions: CPS and medical data can be linked for surveillance. However, the medical data add few unique cases and identify only a subset of maltreated children.

Background: Child death review (CDR) is a mechanism to more accurately describe the causes and circumstances of death among children. The number of states performing CDR has more than doubled since 1992, but little is known about the characteristics of these programs. The purpose of this study was to describe the current status of CDR in the United States and to document variability in program purpose, scope, organization, and process., Methods: Investigators administered a written survey to CDR program representatives from 50 states and the District of Columbia (DC), followed by a telephone interview., Results: All 50 states and DC participated; 48 states and DC have an active CDR program. A total of 94% of programs agreed that identifying the cause of and preventing future deaths are important purposes of CDR. Assistance with child maltreatment prosecution was cited as an important purpose by only 13 states (27%). Twenty-two states (45%) review deaths from all causes, while six states (12%) review only deaths due to child maltreatment. CDR legislation exists in 33 states. Fifty-three percent of the CDR programs were implemented since 1996, and 59% report no or inadequate funding. CDR contributes to the death investigation process in seven states (14%), but the majority (59%) of reviews are retrospective, occurring months to years after the child's death., Conclusions: CDR programs in the United States share commonalities in purpose and scope. Without national leadership, however, the wide variation in organization and process threatens to limit CDR effectiveness.

Objective: Approximately 2000 children die annually in the United States from maltreatment. Although maternal and child risk factors for child abuse have been identified, the role of household composition has not been well-established. Our objective was to evaluate household composition as a risk factor for fatal child maltreatment., Methodology: Population-based, case-control study using data from the Missouri Child Fatality Review Panel system, 1992-1994. Households were categorized based on adult residents' relationship to the deceased child. Cases were all maltreatment injury deaths among children <5 years old. Controls were randomly selected from natural-cause deaths during the same period and frequency-matched to cases on age. The main outcome measure was maltreatment death., Results: Children residing in households with adults unrelated to them were 8 times more likely to die of maltreatment than children in households with 2 biological parents (adjusted odds ratio [aOR]: 8.8; 95% confidence interval [CI]: 3.6-21.5). Risk of maltreatment death also was elevated for children residing with step, foster, or adoptive parents (aOR: 4.7; 95% CI: 1.6-12.0), and in households with other adult relatives present (aOR: 2.2; 95% CI: 1.1-4.5). Risk of maltreatment death was not increased for children living with only 1 biological parent (aOR: 1.1; 95% CI: 0.8-2.0)., Conclusions: Children living in households with 1 or more male adults that are not related to them are at increased risk for maltreatment injury death. This risk is not elevated for children living with a single parent, as long as no other adults live in the home.

Objective: Sudden infant death syndrome (SIDS) is a major cause of infant mortality and is associated with the prone sleeping position. The goal of this study was to determine changes in newborn nursery policies and practices regarding infant sleeping position between 1992 and 1999., Study Design: The researchers conducted telephone interviews with the head nurses in all of the newborn nurseries in Missouri., Population: In 1992 there were 79 hospitals in Missouri with newborn nurseries; in 1999 that number had decreased to 75., Outcomes Measured: During the interviews, the researchers solicited nursery infant sleep position policy and practice, head nurses' opinions about the supine sleep recommendation, and nurses' advice to parents regarding sleep position., Results: In 1992, 32% of the nurseries used the prone position for sleep, and 58% of the head nurses interviewed disagreed with the recommendations of the American Academy of Pediatrics (AAP). By 1999, all newborn nurseries in Missouri placed infants on their backs or sides for sleep. The rate of disagreement with the AAP recommendation had decreased, with 25% of respondents indicating that they disagreed., Conclusions: From 1992 to 1999 nurseries in Missouri have changed from predominantly using prone and lateral positioning to lateral and supine positioning for newborns. Some nurses continue to voice concern about placing infants on their backs and expressed a willingness to place babies prone. Since there is agreement between nurses' usual infant positioning and the advice given to parents, and because both are important influences on infant positioning by parents, future campaigns to decrease SIDS should emphasize correcting nurses' positioning behavior and advising parents to increase infant supine positioning.

Background: Determining a community's health care access needs and testing interventions to improve access are difficult. This challenge is compounded by the task of translating the relevant data into a format that is clear and persuasive to policymakers and funding agencies. Geographic information systems can analyze and transform complex data from various sources into maps that illustrate problems effortlessly for experts and nonexperts., Objective: To combine the patient data of a community health center (CHC) with health care survey data to display the CHC service area, the community's health care access needs, and relationships among access, poverty, and political boundaries., Design: Georeferencing, analyzing, and mapping information from 2 databases., Setting: Boone County, Missouri., Participants: Community health center patients and survey respondents., Main Outcome Measures: Maps that define the CHC service area and patient demographics and show poor health care access in relation to the CHC service area, CHC utilization in relation to poverty, and rates of health care access by geopolitical region., Results: The CHC serves a distinctly different area than originally targeted. Subpopulations with unmet health care access needs and poverty were identified by census tract. These underserved populations fell within geopolitical boundaries that were easily linked to their elected officials., Conclusions: Geographic information systems are powerful tools for combining disparate data in a visual format to illustrate complex relationships that affect health care access. These systems can help evaluate interventions, inform health services research, and guide health care policy. Arch Fam Med. 2000;9:971-978

Background: A comprehensive surveillance system for occupational injuries to adolescents does not exist in Texas, as in most states. Therefore, the magnitude, severity, nature, and source of injuries to working adolescents have not been well described in Texas., Methods: The investigators used three data sources to investigate work-related injuries and deaths in Texas: (1) Texas Workers' Compensation Commission (TWCC) claims data from 1991 through April 1996; (2) 1993 TWCC/Bureau of Labor Statistics (BLS) Annual Survey of Occupational Injuries and Illnesses; and (3) work-related fatalities identified from Texas death certificates from 1990-1995., Results: There were 9,027 injuries reported to the TWCC for adolescents 14-17 years of age during slightly more than 5 years. Injuries for which indemnity payments were made (more than 7 days out of work) occurred among 21.7% of the adolescents. Based on BLS data in 1993, of 992 non-fatal injuries involving days away from work, 35% were caused by contact with objects, 27% by bodily reaction, and 24% by falls. Two-thirds of these injuries occurred while working in eating and drinking places and grocery stores. Three-quarters of the 30 deaths from 1990-1995 were accounted for equally by motor vehicle and homicide., Conclusions: In conclusion, a substantial number of adolescents are injured or killed in the workplace each year in Texas. Although improved population-based surveillance is needed, sufficient knowledge exists to begin prevention efforts now.

Several epidemiologic studies indicate that some paternal occupations are associated with an increased risk of birth defects in offspring. We evaluated this relation using data from a population-based case-control study. Cases are infants with a major birth defect registered with the Metropolitan Atlanta Congenital Defects Program between 1968 and 1980. We selected controls from livebirths in the Atlanta area using frequency matching for race, year, and hospital of birth. Case and control parents were interviewed to solicit information on several factors, including occupation. We classified paternal occupation according to the job held during the time from 6 months before until 1 month after the estimated date of conception. We compared fathers in one occupational category with fathers in all other categories combined. We identified a number of associations including: firemen with cleft lip [odds ratio (OR) = 13.3; 95% confidence interval (CI) = 4.0-44.4]; painters with atrial septal defect (OR = 2.7; 95% CI = 1.0-7.4); and farmers with cleft lip and palate (OR = 3.3; 95% CI = 0.9-11.9). This study, however, did not corroborate several associations found in previous studies, such as painters and neural tube defects. We identified several additional occupations as potential risk factors for some defects, including printers, electronic equipment operators, and vehicle manufacturers.

The use of occupation as a surrogate for workplace exposures when more specific information is unavailable is common yet is particularly challenging in studies involving many diverse occupations. A classification scheme that aggregates workers based on similar job tasks and potential exposures was developed for use in a Canadian study, and its adaptation for a similar U.S. study is described. The 56 occupational categories and 1980 U.S. census occupation and industry codes used to create each are presented. The scheme was developed using the distribution of occupations and industries in two limited study populations, and no exposure measurements were taken in its preparation. However, the aggregation of jobs with similar exposures has practical utility in the analysis of a large number of specific occupations, each with a small number of workers. As a result, the scheme presented can provide a starting point for researchers facing this task in the analysis of case-control occupational data.

Agreement between the mother's and father's report of the father's occupation was assessed in a case-control study of paternal occupation and birth defects. Cases were identified from births registered with the Metropolitan Atlanta Congenital Defects Program between 1968 and 1980; controls were selected from liveborn infants without defects. Both parents were sought for interview, and each parent was asked about the father's job history for 2 years prior to the infant's death. This concordance analysis is based on 3,739 case infants and 2,279 control infants for whom both parents were interviewed. The authors considered the father's report of his occupation as correct, and they assessed the ability of the mother to report the same occupation(s) during a 7-month period around conception. The exact agreement between mother's and father's report of the father's occupation was 59%. Agreement improved slightly with increasing family income and when fathers were college graduates. Female partners were not accurate proxy respondents in this study of paternal occupation and birth defects, which suggests that investigators should interview both parents in studies of paternal exposures and reproductive outcomes, i.e., mothers for pregnancy history and maternal confounders and fathers for occupational history and paternal confounders.

The effect of paternal age on the risk of birth defects among offspring is less well studied than the effect of maternal age, with few comprehensive epidemiologic studies having been conducted. Advanced paternal age has been shown to be associated with an increase in new dominant mutations that result in particular congenital anomalies. The relationship between paternal age and more common birth defects, for example, cardiac defects, has not been as extensively evaluated. Therefore, a total of 4,110 cases of congenital heart defects was identified from the British Columbia Health Surveillance Registry. Matched controls were obtained from the birth files of British Columbia for the years 1952-1973. Prevalence odds ratios for paternal age, adjusted for maternal age and other factors, were estimated for 8 cardiac defect groups. A suggestive general pattern of increasing risk with increasing age among cases (excluding chromosomal anomalies) relative to controls was found for ventricular septal defects (VSD), atrial septal defects (ASD), and patent ductus arteriosus (PDA). In addition, an increased risk among men younger than 20 yr was found for VSD and ASD. These findings are consistent with the results of some previous epidemiologic studies. Based on the results of this study it is estimated that for cardiac defects such as VSD, approximately 5% of cases may be due to advanced paternal age (> 35 yr), possibly through dominant mutations.

Alaska Native women historically have high rates of sexually transmitted diseases (STDs) and invasive cervical cancer. Their prevalence of cervical infections with human papillomavirus (HPV) in relation to cervical dysplasia was determined with a commercial dot hybridization test for seven HPV genotypes. Type-specific HPV DNA, similarly distributed between genotype groups 16/18 and 31/33/35, was detected in 234 cervical specimens (21%) from 1126 Alaska Native women seeking routine care and colposcopy or from population-based lists. The prevalence of HPV DNA declined with age and increased with sexual activity and cigarette smoking. It was unrelated to use of oral contraceptives or condoms or to STDs. Relative risks associating HPV with increasing severe grades of cervical dysplasia increased markedly with HPV infection, up to 7.1 for high-risk genotypes 16/18 and 14.4 for coinfection with 31/33/35. These genotypes were detected in 8% of women without dysplasia seeking routine care. Screening for strain-specific HPV DNA may identify women at highest risk for cervical neoplasia.

Objectives: Studies from other countries have identified fishing as a hazardous industry, but little is known about occupational injury mortality related to fishing in the United States. Alaska was chosen for this study because approximately 45,000 people annually participate in Alaska's fishing industry and fishing is thought to be a major contributor to occupational injury mortality in the state., Methods: Work-related injury deaths in Alaska's fishing industry were identified by means of death certificates and US Coast Guard mortality data. Fatality rates were calculated by using average annual fishing industry employment estimates., Results: The 5-year average annual fishing-related fatality rate was 414.6 per 100,000 fishermen. The majority of the decedents were Caucasian men who drowned while fishing., Conclusions: This study emphasizes that fishing is a dangerous industry in Alaska and demonstrates the benefit of using multiple data sources to identify fishing-related deaths in the state.

Patients evaluated by paramedics but not transported to the hospital account for 50% to 90% of emergency medical services lawsuits. We reviewed 2,698 consecutive paramedic run reports to examine documentation in these cases. Documentation criteria for prehospital patient release were history, physical examination, vital signs, mental status, lack of significant mental impairment, and for patients refusing care, that risks of refusing were understood. Criteria for appropriate release were met in 65.2% of cases. Criteria omitted in inappropriate releases were risks of refusing care in 481 (51.3% of inappropriate releases), vitals in 320 (34.1%), mental status in 188 (20.0%), lack of impairment in 120 (12.8%), and history or physical in 19 (2.0%) cases. Age from 0 to 14 and 65 or more years and prehospital assessment of hyperventilation, psychiatric emergency, choking, infection, and patient deceased were significantly associated with appropriate release. Age from 35 to 54 years and prehospital diagnosis of no injury, head injury, seizure, minor trauma, and ethanol use were significantly associated with inappropriate releases. There was no association of appropriate release or inappropriate release with patient sex, contact with medical control, length of encounter, or time of day. Only one patient complication was believed due to inappropriate triage; this could be improved by implementation of standardized criteria.

A consecutive series of 67 patients who had sustained self-inflicted gunshot wounds of the brain was reviewed retrospectively to evaluate factors determining outcome. Weapon caliber, site of bullet entry, degree of brain wounding on computerized tomographic scan, and presenting Glasgow Coma Scale (GCS) score were examined. Overall mortality, degree of disability in survivors, and survival time after injury in fatally wounded patients were assessed. Ninety-eight percent of all patients with an initial GCS score of 8 or less died. When the GCS score was more than 8, 91% of patients survived (P less than .0001). Survival rate was significantly increased in patients with injury limited to one lobe of the brain, compared with patients with brain wounds of greater severity demonstrated on computerized tomographic scan (P less than .05), while a missile crossing both vertical anatomic planes of the brain or coming to rest in the posterior fossa was lethal in 100% of cases. Survivors scored relatively well on the Glasgow Outcome Scale. Almost all (98%) fatally injured patients maintained vital functions for a time ample for transportation and evaluation at a major referral center. These findings hold important implications for trauma center and critical care resource allocation as well as organ transplantation programs.