Response to "COVID-19 and impact on trauma injuries. A Janus facing in opposite directions?" by Drs. Sotiropoulou, Vailas, and Kapirisin, a Letter to the Editor regarding "The influence of a statewide stay-at-home order on trauma volume and patterns at a level 1 trauma center in the United States".

Dear Editor,

We enjoyed reading Drs. Sotiropoulou, Vailas, and Kapirisin's Letter to the Editor [1] in response to our article “The Influence of a Statewide “Stay-at-Home” Order on Trauma Volume and Patterns at a Level 1 Trauma Center in the United States” [2] and appreciated the opportunity to learn about their experience during the COVID pandemic at the Evangelismos General Hospital in Athens, Greece.

Similar to our reported observations, the authors experienced a significant decrease in trauma volume during the height of the COVID pandemic in 2020, but they saw a dramatic upsurge in penetrating trauma, often involving substance abuse and violent intent [1]. These changes are particularly striking given the generally much lower incidence of gunshot- and stab wounds seen at most European trauma centers as compared to the United States. The observations by Dr. Sotiropoulou and her colleagues are consistent with many reports on persistent or even surging violent and penetrating trauma throughout the height of the COVID pandemic [3], [4], [5], supporting the widely described concerns about the toll on mental health and society in general the COVID pandemic and its associated social isolation and economic implications has taken [6], [7], [8]. We also had the unfortunate experience that soon after the initial decline in trauma volume due to lockdown measures in March and April 2020, the incidence of trauma cases (including penetrating and violent trauma) began to rise again rapidly, eventually reaching and exceeding pre-pandemic levels for the year 2020 and continuing this trend in 2021.

In summary, we agree with Drs. Sotiropoulou, Vailas, and Kapirisin that COVID had dramatic effects on healthcare systems and people's everyday lives worldwide and continues to do so. Analyses of these consequences unfortunately remain highly pertinent as COVID cases once again surge in regions across the world and lockdown measures are being discussed.