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This study investigated patterns of cortical organization in adolescents who had sustained a traumatic brain injury (TBI) during early childhood to determine ways in which early head injury may alter typical brain development. Increased gyrification in other patient populations is associated with polymicrogyria and aberrant development, but this has not been investigated in TBI. Seventeen adolescents (mean age = 14.1 ± 2.4) who sustained a TBI between 1–8 years of age, and 17 demographically-matched typically developing children (TDC) underwent a high-resolution, T1-weighted 3-Tesla magnetic resonance imaging (MRI) at 6–15 years post-injury. Cortical white matter volume and organization was measured using FreeSurfer's Local Gyrification Index (LGI). Despite a lack of significant difference in white matter volume, participants with TBI demonstrated significantly increased LGI in several cortical regions that are among those latest to mature in normal development, including left parietal association areas, bilateral dorsolateral and medial frontal areas, and the right posterior temporal gyrus, relative to the TDC group. Additionally, there was no evidence of increased surface area in the regions that demonstrated increased LGI. Higher Vineland-II Socialization scores were associated with decreased LGI in right frontal and temporal regions. The present results suggest an altered pattern of expected development in cortical gyrification in the TBI group, with changes in late-developing frontal and parietal association areas. Such changes in brain structure may underlie cognitive and behavioral deficits associated with pediatric TBI. Alternatively, increased gyrification following TBI may represent a compensatory mechanism that allows for typical development of cortical surface area, despite reduced brain volume.

BackgroundFirearm-related injuries are the second leading cause of death among US children. Given this, firearm injury prevention should be a key aspect of pediatric anticipatory guidance.ObjectiveWe assessed the impact of a firearm safety counseling workshop on pediatric resident knowledge, self-efficacy, and self-reported practice patterns.MethodsSixty of 80 residents (75%) participated in a 2-hour multimodal workshop, including video, didactics with experts, and role-play scenarios. Participants were invited to complete pre-workshop, immediate post-workshop, and 3- and 6-month post-workshop self-reported questionnaires evaluating knowledge, comfort, perceived barriers, and reported practice patterns. Data comparing pre- and 6-month post-workshop practice patterns were analyzed via Fischer's exact test. Remaining statistical analysis utilized a one-sided, unpaired Mann–Whitney U test. A binomial exact proportions test was used for open-ended responses.ResultsAfter the workshop, the percentage of participants with perceived concern regarding parental barriers decreased significantly (24% to 7%, P = .001). Participants 6 months post-workshop were 5.14 times more likely to counsel their patients on firearms during more than 75% of their well visits than prior to the intervention (P = .010). Participants reported greater comfort asking patients about firearms, with mean Likert scores increasing from 3.81 pre to 4.33 post (P = .022), which was similar to 3-month (4.39, P = .06) and 6-month evaluations (4.54, P = .003).ConclusionsEducation on firearm safety counseling improved pediatric resident comfort level in discussing the topic. This impact persisted 6 months after the workshop, implying a sustained change in attitudes and behaviors.

Mediation analysis was used to investigate the role of white matter integrity in the relationship between injury severity and verbal memory performance in participants with chronic pediatric traumatic brain injury (TBI). DTI tractography was used to measure fractional anisotropy (FA) within the corpus callosum, fornix, cingulum bundles, perforant pathways, and uncinate fasciculi. Injury severity was indexed using Glasgow Coma Scale (GCS) scores obtained at the time of the injury. Verbal memory was measured by performance on the long-delay free recall (LDFR) trial of the California Verbal Learning Test–Children’s version. Participants were between the ages of 10–18 and included 21 children with TBI (injured before age 9) and 19 typically-developing children (TDC). Children with TBI showed lower FA across all pathways and poorer LDFR performance relative to TDC. Within the TBI group, mediation analysis revealed neither a significant total effect of GCS on LDFR nor significant direct effects of GCS on LDFR across pathways; however, the indirect effects of GCS on LDFR through FA of the corpus callosum, left perforant pathway, and left uncinate fasciculus were significant and opposite in sign to their respective direct effects. These results suggests that the predictive validity of GCS for LDFR is initially suppressed by the substantial variance accounted for by FA, which is uncorrelated with GCS, and the predictive validity of GCS increases only when FA is considered, and the opposing path is controlled. These findings illustrate the complex associations between acute injury severity, white matter pathways, and verbal memory several years following pediatric TBI.

OBJECTIVES The objectives of this study were to estimate the prevalence of cell phone and computer use among urban families bringing their children to an emergency department and to determine which technologies parents prefer to use to receive health information. METHODS We visited 2 pediatric emergency departments in Baltimore, Md, and Little Rock, Ark. A convenience sample of parents of children 8 years old or younger completed a self-administered survey in the waiting area. RESULTS Two hundred thirty-eight surveys were completed. Respondents were primarily female (83%), less than 35 years old (74%), and had at least a high school diploma or General Educational Development (94%). Forty-three percent were employed full time. A majority (95%) of respondents reported owning a cell phone, with most (88%) owning a smartphone and 96% reported having some internet access. Of cell phone owners, 91% reported daily text messaging activity. Over half (63%) of respondents reported having computer internet access at home; 31% reported having internet access at work. Patterns of behavior and preferences emerged for both cell phone and computer use. Respondents were more likely to check their email (75% vs 50%, P < 0.0001) and access the internet (78% vs 67%, P = 0.002) with a smartphone rather than their computer. CONCLUSIONS Both cell phones and computers are prevalent and used among urban families seen in pediatric emergency departments, offering new ways to deliver health information to these often underserved populations. Providers aiming to deliver health information should consider smartphone applications, text message-based programs, and email to communicate with their patients.

Purpose: Research demonstrates that children receive twice as much medical radiation from Computed Tomography (CT) scans performed at non-pediatric facilities as equivalent CTs performed at pediatric trauma centers (PTCs). In 2014, AFMC outreach staff educated Emergency Department (ED) staff on appropriate CT imaging utilization to reduce unnecessary medical radiation exposure. We set out to determine the educational campaign’s impact on injured children received radiation dose. Methods: All injured children who underwent CT imaging and were transferred to a Level I PTC during 2010 to 2013 (pre-campaign) and 2015 (post-campaign) were reviewed. Patient demographics, mode of transportation, ED length of stay, scanned body region, injury severity score, and trauma center level were analyzed. Median effective radiation dose (ERD) controlled for each variable, pre-campaign and post-campaign, was compared using Wilcoxon rank sum test. Results: Three hundred eighty-five children under 17 years were transferred from 45 and 48 hospitals, pre- and post-campaign. Most (43%) transferring hospitals were urban or critical access hospitals (30%). Pre- and post-campaign patient demographics were similar. We analyzed 482 and 398 CT scans pre- and post-campaign. Overall, median ERD significantly decreased from 3.80 to 2.80. Abdominal CT scan ERD declined significantly from 7.2 to 4.13 (P-value 0.03). Head CT scan ERD declined from 3.27 to 2.45 (P-value < 0.0001). Conclusion: A statewide, CT scan educational campaign contributed to ERD decline (lower dose scans and fewer repeat scans) among transferred injured children seen at PTCs. State-level interventions are feasible and can be effective in changing radiology provider practices.

Introduction:Sudden unexpected infant death is the leading cause of infant mortality with black: white infant mortality remaining at 2:1 for the last decade. Smartphone technology provides a convenient and accessible tool for injury prevention anticipatory guidance among at-risk communities.Materials and Methods:A convenience sample of pregnant teen mothers who own a smartphone. During a 1-month postnatal home visit, a safe sleep environment survey was administered, infant sleep practices were observed, and mothers trained to take and submit standard infants’ sleep environment photographs. Photographs were independently assessed for inter-rater reliability (IRR) across five sleep safety domains (primary outcome): sleep location, surface, position, presence of soft items, and hazards near the sleep area. Expert and novice coders IRR was measured using Cohen’s kappa coefficient (K). Sleep safety correlation between photographs and observation, and parent report and observation was determined.Results:Sixteen (57.1%) mothers completed the home visit. Most parents reported infants sleeping supine (78.5) in parents’ bedroom (85.9%). Photographs demonstrated sleep position, soft items without the baby present, and hanging toys had perfect agreement across all three coder pairs. Safe sleep experts’ IRR demonstrated perfect agreement for sleep location, position, and soft items. While 83.8% of parents were observed putting their infants down to sleep on their back, 78.5% of parents reported doing the same and 82.4% of the photographs demonstrated supine infant sleep position.Conclusion:Using photographs, coders can reliably categorize some key infant sleep safety aspects, and photograph sleep safety is comparable to parent report and direct observation.

OBJECTIVES: All-terrain vehicle (ATV) crashes have been responsible for significant injuries among children, despite public education efforts. Our study examined pediatric ATV injury patterns in US emergency departments (EDs) compared with injuries after motor vehicle crash (MVC) and sports activities. METHODS: We studied 2006 to 2011 data from the Nationwide Emergency Department Sample. Children younger than 18 years and involved in ATV crashes, MVC, or sports activities were included. The primary outcome analyzed was a constructed binary measure identifying severe trauma, defined as injury severity score greater than 15. Logistic regression models were fit to determine the association between mechanism of injury and severe trauma. RESULTS: A total of 6,004,953 ED visits were identified. Of these, ATV crashes accounted for 3.4%, MVC accounted for 44.7%, and sports activities accounted for 51.9%. Emergency department visits after ATV crashes were more likely to result in admission (8%) and incur higher median charges ($1263) compared with visits after sports activities (1%, $1013). Visits after sports activities were 90% less likely to result in severe trauma when compared with ATV crash visits. Emergency department visits after ATV crashes result in severe injuries similar to those sustained in MVC (odds ratio, 1.03; P = 0.626). CONCLUSIONS: Pediatric ED visits after ATV crashes result in significant injuries and charges. Public health interventions such as education, legislation, and engineering are needed to reduce injuries among children and the subsequent ED visits for care. The impact of proven interventions may be greatest for children living in rural areas and among older children, 10 to 17 years old. Language: en

The growing interest in incorporating prevention into emergency health care make it timely to examine the use of computer technology to efficiently deliver effective education in this setting.This RCT compared results from an intervention group (n=367) that received child passenger safety information, to an attention-matched control (n=375). A baseline survey and two follow-up surveys at 3 and 6 months were conducted.Data were collected from June 2014 to September 2016 from a sample of parents with children aged 4-7 years recruited from a pediatric emergency department in an East Coast urban area and one in a Midwest semi-rural area.A theory-based, stage-tailored educational program, Safety in Seconds v2.0Four car seat behaviors: (1) having the correct restraint for the child's age and weight; (2) having the child ride in the backseat all the time; (3) buckling up the child all the time; and (4) having the child's restraint inspected by a child passenger safety technician.At 3 months, adjusting for baseline behaviors and attrition, the odds of reporting the correct behavior by the intervention group relative to the control group was 2.07 (p0.01) for using the correct car seat; 2.37 (p0.05) times for having the child ride in the back seat; 1.04 (nonsignificant) for riding buckled up all the time; and 1.99 (p0.01) times for having the car seat inspected. At 6 months, there were statistically significant effects for reporting use of the correct car seat (OR=1.84, p0.01) and having the car seat inspected (OR=1.73, p0.01).Mobile apps hold promise for reaching large populations with individually tailored child passenger safety education.Clinical Trial Registration # NCT02345941.

Purpose Sudden Infant Death Syndrome (SIDS) and suffocation account for more than half of all Sudden Unexpected Infant Deaths (SUID). The American Academy of Pediatrics (AAP) recommendations describe the safest environments to protect infants. This study compared parent responses on the Newborn Sleep Safety Survey and observational assessments ( N = 72) of infant sleep environments in families thought to be at high-risk for non-compliance with AAP recommendations. Design and Methods A naturalistic study of participants enrolled in two home visitation support programs was used. Observed risks ranged from 36.6% (never use pacifier) to 4.3% (never use firm mattress). Results Results comparing report to observation demonstrated acceptable concordance. Five items had fair concordance (Kappa > .4), four showed moderate concordance (Kappa > .6), and one excellent concordance (Kappa > .8). Although direct observation of safety behaviors is the gold standard in the injury prevention field, direct observation is logistically difficult, time consuming, and costly. Conclusions Research and interventions aimed at a reduction of Sudden Infant Death Syndrome (SIDS) and suffocation require accurate assessment of the infant sleep environment. This study provides acceptable evidence for the use of the Newborn Sleep Safety Survey as an alternative to direct observation to assess parent adherence to recommendations. Limitations are discussed. Practical Implications This study provided evidence of the usefulness of the Newborn Sleep Safety Survey , a parent survey of infant sleep environments. This tool will provide medical and research professionals a reliable, inexpensive tool to evaluation of the quality of sleep environments using a standard definition.

Purpose The long-term cancer risks for children exposed to radiologic images can be two to three times higher than for adults because children are more sensitive to radiation and have a longer lifetime in which to accumulate exposure from CT scans. Injured children often undergo repeat CT imaging if they are transferred from non-pediatric hospitals to a Level I pediatric trauma center (PTC). This study determined the impact of a statewide web-based image repository (WBIR) on repeat imaging among transferred injured children. Methods All injured children who underwent CT imaging and were transferred to the PTC in 2010 (pre-WBIR) and 2013 (post-WBIR) were included. Patient-level factors studied included demographics, body region of scan, Injury Severity Score, and Emergency Department (ED) disposition. Change from pre to post on rate of repeat imaging was assessed. Results Two hundred fifty-four and 233 children, with a median age of 7.3 years, were transferred to the Children's Hospital in 2010 and 2013, respectively. Repeat imaging levels at the PTC were lower post-WBIR than pre-WBIR (20% versus 33%, odds ratio [OR] 0.54, P = .005). Images of the head decreased most significantly (60% versus 33%, OR 0.33). Images performed at Level II and III trauma centers were repeated less often after WBIR. Conclusions The WBIR significantly reduced repeat imaging among injured children transferred to a PTC, especially children transferred from Level II and Level III trauma centers, children with lower-acuity injuries, and children with initial scans of the head. Radiation savings are expected to be beneficial to children.

In this paper, an infant sleep prevention solution based on semantic to access infant environmental hazards is presented. To promote safe sleep evaluation and implement sustainability in rural underserved communities, we use deep learning techniques to automatically assess photographs of the infant's sleep environment and report unsafe environments. To achieve this, we first built and labeled a dataset of 626 images from infants in various sleep positions and environments. The segmentation architecture is composed of a downsampling path responsible for extracting coarse semantic features, followed by an upsampling path trained to recover the input image resolution and finally, a pixel-wise classification layer. The trained model is also integrated into an android application to provides a sustainable evaluation/assessment tool. We achieve state-of-the-art results and demonstrated that the automated assessment system could identify safe/unsafe sleep environment using photographs.

Background Sudden infant death syndrome (SIDS) and suffocation are leading causes of infant mortality. Supine sleep position and use of appropriate sleep surfaces reduce SIDS risk but are not universally practiced. Mothers’ decisions about sleep position and environment may be influenced by guidance provided by infants’ grandmothers and other caregivers. Methods A survey was conducted of a convenience sample of grandmothers aged 30–70 years who provide care at least weekly for an infant grandchild

Current American Academy of Pediatrics recommendations regarding transition from child safety/booster seat to adult safety belt use indicate that children should be at least 4 feet 9 inches, 8 years old, or 80 pounds. Proper fit in the vehicle seat, assessed with a five-point fit test, should also be met. Although most children reach 4 feet 9 inches around age 8 years, each child and vehicle presents a unique combination; thus a child may not fit appropriately in all vehicle types using only the 4 feet 9 inches requirement.We enrolled children, aged 7 years to 12 years, into our study. Height, weight, and demographic data were obtained. A Child Passenger Safety Technician then performed the five-point fit test in each of a uniform lineup of five vehicles. Data were collected on fit in the standard vehicle seat and also in a booster seat. We set 90% as the threshold proportion of children who meet all criteria for proper fit to validate current recommendations of a height of 4 feet 9 inches.Data were collected on 388 children. The percentage of 90% proper fit was met in the compact car and small sport-utility vehicle (SUV). However, only 80 (77%) of 104 students (p0.0001) that were 4 feet 9 inches or higher fit properly in the large SUV, only 87 (83%) of 105 students (p = 0.02) fit properly in the pickup truck, and only 91 (89%) of 102 students (p = 0.74) fit properly in the minivan.Substantial proportions of children meeting current height guidelines for an adult seat belt do not meet safety requirements for fit, especially in larger, commonly used vehicles (large SUVs and trucks). This emphasizes the need for evaluation of fit by a trained personnel and/or development of standard back seat dimensions in all vehicles for maximum safety.Epidemiologic study, level III; Therapeutic study, level V.

Purpose Although child safety seats are known to reduce the risk of death from motor vehicle crashes, use among children 4–7 years old remains low and misuse is widespread. The aim of this prospective randomised trial was to test the efficacy of a smartphone app, Safety In Seconds 2.0, which delivered theory-based tailored education about child safety seats to parents in Little Rock, Arkansas and Baltimore, Maryland Methods Parents of children aged 4–7 visiting the paediatric emergency room in the two participating sites (regardless of the reason for the visit) were recruited. Study participants downloaded the Safety In Seconds app onto their smartphone and were randomised to the intervention (car seat) or control (fire safety) group. Both groups completed a 10 min assessment about their safety knowledge and behaviours and received tailored feedback relevant to their study group. The app contained a portal with educational links and sent monthly push notification reminders for parents to interact with the app. Parents completed follow-up assessments at 3 months and 6 months. Results A total of n=1129 parents were enrolled, and 742 (66%) completed the 6 month follow-up survey. At follow-up relative to the CG, IG parents were more likely to report using the correct child safety seat for their child’s age and size (OR=1.8; p Conclusions/Significance Smartphone applications hold potential for changing behaviours that are known to improve child passenger safety.

Background Smoke alarms have been demonstrated to reduce the risk of death in fire. It is recommend that families develop and practice fire escape plans. This study aims to utilise a smartphone app, Safety In Seconds, to deliver a theory-based tailored education to improve fire safety practices of parents in Little Rock, Arkansas and Baltimore, Maryland Methods Parents of children aged 4–7 visiting the paediatric emergency room in the two participating sites (regardless of the reason for the visit) were recruited. With assistance from a research assistant study participants downloaded the Safety In Seconds app onto their smartphone and were randomised to the intervention (fire safety) or control (car seat) group. Both groups completed a 10 min assessment about their safety knowledge and behaviours and received tailored feedback relevant to their study group. The app contained a portal with educational links and sent monthly push notification reminders for parents to interact with the app. Parents completed follow-up assessments at 3 months and 6 months. Results A total of n=1129 parents were enrolled, and 742 (66%) completed the 6 month follow-up survey. At follow-up relative to the CG, parents in the IG were more likely to report having long-life lithium battery smoke alarms (22% vs 16%; p=0.03) and having practiced a fire escape plan (65% vs. 71%; p=0.08). Conclusions Smartphone applications may be a promising tool to improve home safety behaviours.

Use of cranial CT scans in children has been increasing, in part due to increased awareness of sports-related concussions. CT is the largest contributor to medical radiation exposure, a risk factor for cancer. Long-term cancer risks of CT scans can be two to three times higher for children than for adults because children are more radiosensitive and have a longer lifetime in which to accumulate exposure from multiple scans.To compare the radiation exposure injured children receive when imaged at nonpediatric hospitals (NPHs) versus pediatric hospitals.Injured children younger than 18 years who received a CT scan at a referring hospital during calendar years (CYs) 2010 and 2013 were included. Patient-level factors included demographics, mode of transportation, and Injury Severity Score, and hospital-level factors included region of state, radiology services, and hospital type and size. Our primary outcome of interest was the effective radiation dose.Four hundred eighty-seven children were transferred to the pediatric trauma center during CYs 2010 and 2013, with a median age of 7.2 years (interquartile range 5-13). The median effective radiation dose received at NPHs was twice that received at the pediatric trauma center (3.8 versus 1.6 mSv, P.001). Results were confirmed in independent and paired analyses, after controlling for mode of transportation, emergency department disposition, level of injury severity, and at the NPH trauma center level, hospital type, size, region, and radiology services location.NPHs have the potential to substantially reduce the medical radiation received by injured children. Pediatric CT protocols should be considered.

BACKGROUND: Booster seats reduce mortality and morbidity for young children in car crashes, but use is low, particularly in rural areas. This study targeted rural communities in 4 states using a community sports-based approach. OBJECTIVE: The Strike Out Child Passenger Injury (Strike Out) intervention incorporated education about booster seat use in children ages 4-7 years within instructional baseball programs. We tested the effectiveness of Strike Out in increasing correct restraint use among participating children. METHODS: Twenty communities with similar demographics from 4 states participated in a nonrandomized, controlled trial. Surveys of restraint use were conducted before and after baseball season. Intervention communities received tailored education and parents had direct consultation on booster seat use. Control communities received only brochures. RESULTS: One thousand fourteen preintervention observation surveys for children ages 4-7 years (Intervention Group [I]: N = 511, Control [C]: N = 503) and 761 postintervention surveys (I: N = 409, C: N = 352) were obtained. For 3 of 4 states, the intervention resulted in increases in recommended child restraint use (Alabama +15.5%, Arkansas +16.1%, Illinois +11.0%). Communities in 1 state (Indiana) did not have a positive response (-9.2%). Overall, unadjusted restraint use increased 10.2% in intervention and 1.7% in control communities (P = .02). After adjustment for each state in the study, booster seat use was increased in intervention communities (Cochran-Mantel-Haenszel odds ratio 1.56, 95% confidence interval [1.16-2.10]). CONCLUSIONS: A tailored intervention using baseball programs increased appropriate restraint use among targeted rural children overall and in 3 of 4 states studied. Such interventions hold promise for expansion into other sports and populations. Language: en

OBJECTIVES: Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population. METHODS: A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions. RESULTS: Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02). CONCLUSIONS: In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified. Language: en

Background Although proven measures for reducing injury due to motor vehicle collision and residential fires exist, the number of families properly and consistently using child passenger restraints and smoke alarms remains low. This paper describes the design of the Safety In Seconds (SIS) 2.0 study, which aims to evaluate the impact of a smartphone app on parents9 use of child restraints and smoke alarms. Methods SIS is a multisite randomised controlled trial. Participants are parents of children aged 4–7 years who are visiting the Pediatric Emergency Department or Pediatric Trauma Service. Parents are randomised to receive tailored education about child passenger safety or about fire safety via the SIS smartphone app. A baseline and two follow-up surveys at 3 months and 6 months are conducted. Primary outcomes are: (1) having the correct child restraint for the child9s age and size; (2) restraining the child in the back seat of the car; (3) buckling the child up for every ride; (4) having the restraint inspected by a child passenger safety technician; (5) having a working smoke alarm on every level of the home; (6) having hard-wired or lithium battery smoke alarms; (7) having and (8) practising a fire escape plan. Discussion Finding ways to communicate with parents about child passenger and fire safety continues to be a research priority. This study will contribute to the evidence about how to promote benefits of proper and consistent child restraint and smoke alarm use. Trial registration number NCT02345941; Pre-results.

Since 2006, the National Institutes of Health has provided institutional infrastructure grants, called Clinical and Translational Science Awards (CTSAs), to support adult and pediatric clinical and translational research in United States institutions. A CTSA Consortium Child Health Oversight Committee workgroup developed metrics to measure the impact of CTSAs on child health (CH) research. A cross-sectional survey to collect metric data was distributed to the 46 institutions that received CTSAs during 2006-09. Thirty-seven (80%) institutions responded to the survey. Data regarding 7 metrics were reported by >70% of responding institutions: the proportion of overall funding (median, interquartile range; 0.12, 0.06–0.19) and pilot grants (0.15, 0.11–0.21) supporting CH research; the proportion of active clinical research center studies involving children (0.23, 0.15–0.35); the proportion of IRB-approved (0.24, 0.16–0.30) and funded (0.22, 0.18–0.30) studies involving children; the proportion of mentored research training awards to CH investigators (0.18, 0.11–0.28); and, the proportion of CTSA leadership positions held by pediatricians (0.18, 0.12–0.28). CTSAs provide substantial support for CH research, although additional investment in CH research is needed to improve the health of children. These metrics provide an initial means to track the impact of CTSAs on CH research.

The objective of this study was to summarize basic information on the characteristics of work-related A TV deaths among civilian persons 18 years of age or older in the U.S. from 1992 through 2007. Work-related ATV death data were obtained through the Bureau of Labor Statistics' annual Census of Fatal Occupational Injuries. From 1992 to 2007, 297 work-related ATV deaths occurred among persons over 17 in the U.S. Ninety-two percent were male, 93% were white, 23% were ages 18 to 34, 51% were ages 35 to 64, and 26% were agesor = 65. Half of the fatal incidents involved overturns resulting in head and chest injuries. Sixty percent of crashes occurred on farms and 20% occurred on highways. The fatality rate among agricultural production workers was significantly higher than the rates in all other industries. While more in-depth analysis of incident and exposure data for this growing problem will more clearly define personal risk and causal factors in the long term, in the short term, stronger emphasis must be placed on the development of prevention strategies, particularly focused on older workers in the agriculture production industry.

Although injury is a major cause of death and disability, concepts of injury prevention have not been present in the curricula of most medical schools. There have been recent calls in the literature, including a 2005 report from the Association of American Medical Colleges, for the addition of injury prevention concepts into medical school education. This report describes the process of development of a longitudinal injury prevention curriculum in one medical school. The curriculum committee felt that adding the material in a longitudinal fashion would better correlate the material to the rest of the curriculum as well as provide efficiency in the already crowded undergraduate programme of study. The report describes the content of the longitudinal curriculum developed as well as initial evaluation of the material.

Controlling for injury and patient characteristics, one would expect comparable in-hospital outcomes for injured patients with and without epilepsy. The historical stigma associated with epilepsy is well-documented, yet potential disparities in injury care for people with epilepsy/seizures have not been examined. We compared in-hospital outcomes of injured patients with epilepsy/seizures with patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy have worse outcomes. Methods: Existing data were analyzed from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Injured patients of all ages were included. Multivariable logistic regression was used to control for patient and hospital characteristics. Main outcome measure: in-hospital mortality. Results: When controlling for patient and injury characteristics, our results show that people with epilepsy/seizures were more likely to die in-hospital than people without epilepsy odds ratio (OR) 1.17, p Language: en

Children ages 8-12 years, also called "Tweens," demonstrate a number of risk factors for motor vehicle injury, including lack of restraint use and front seating position, yet few interventions have targeted this group. We implemented a school-based educational intervention designed to increase awareness and encourage safer transportation of these children.A local school collaborated with the study team to develop educational materials based on the school mascot and allowed use of school-based media (bulletin boards, closed circuit TV, and newsletters) to deliver key messages about restraint use and back seating position. Selected students participated in delivering the message and in evaluation activities, increasing peer support for the program. Evaluation consisted of surveys of reported and observed restraint use and rear seating for children and restraint use for parents before and after the educational intervention.School support for the program was excellent and student enthusiasm was high. Parent awareness of safe positioning for children improved, with parents endorsing seat belts alone versus seat belts with a booster seat for children ages 5-8 falling from 37% to 25% (p0.004). Child report of restraint use increased from 78% to 89% (p0.001). Reported exposure to the campaign messages was high with 77% of parents and 89% of students recalling the campaign at the end of the year. Observed restraint use for both adults and children was somewhat lower than reported use. Restraint use by parents was about 80% both before and after the intervention. Restraint use by children increased from 71% to 91% (0.001). No changes were noted in front seating position for children.Short term positive changes in observed restraint use and knowledge about safer transportation of children were encouraging. Further study of the program, including a controlled study of the intervention, are needed to demonstrate longer term effectiveness.

Child passenger safety remains an important public health problem because motor vehicle crashes are the leading cause of death for children, and the majority of children ride improperly restrained. Using a mobile app to communicate with parents about injury prevention offers promise but little information is available on how to create such a tool. The purpose of this article is to illustrate a theory-based approach to developing a tailored, smartphone app for communicating child passenger safety information to parents. The theoretical basis for the tailoring is the elaboration likelihood model, and we utilized the precaution adoption process model (PAPM) to reflect the stage-based nature of behavior change. We created assessment items (written at ≤6th grade reading level) to determine the child's proper type of car seat, the parent's PAPM stage and beliefs on selected constructs designed to facilitate stage movement according to the theory. A message library and template were created to provide a uniform structure for the tailored feedback. We demonstrate how messages derived in this way can be delivered through new m-health technology and conclude with recommendations for the utility of the methods used here for other m-health, patient education interventions. Language: en

Objective: To discuss the successes and challenges associated with the implementation of a post-traumatic stress disorder (PTSD) screening tool in two pediatric emergency departments (ED). Methods: The STEPP screening tool has been developed previously on an inpatient population of motor vehicle trauma patients. It was applied here to the general ED population at two different pediatric trauma centers. Nurse screeners were trained and a convenience sample of patients with unintentional injuries who met study criteria were screened in the ED. Feedback from nurse screeners was obtained. Results: The process of implementing a screening tool to identify patients and their families significantly at risk for PTSD symptomatology presented some barriers, but overall acceptability of the process was high for both the emergency department staff and the patient. Recommendations for others considering implementation of screening programs in the ED are offered. Conclusions: Future research using screening protocols in the ED should, in their design, attempt to capitalize on the successes identified in the current protocol and circumvent barriers also encountered.

OBJECTIVE. Children with moderate to severe traumatic brain injury (TBI) show early neurobehavioral deficits that can persist several years after injury. Despite the negative impact that TBI can have on a child's physical, cognitive, and psychosocial well-being, only 1 study to date has documented the receipt of health care services after acute care and the needs of children after TBI. The purpose of this study was to document the health care use and needs of children after a TBI and to identify factors that are associated with unmet or unrecognized health care needs during the first year after injury. METHODS. The health care use and needs of children who sustained a TBI were obtained via telephone interview with a primary caregiver at 2 and 12 months after injury. Of the 330 who enrolled in the study, 302 (92%) completed the 3-month and 288 (87%) completed the 12-month follow-up interviews. The health care needs of each child were categorized as no need, met need, unmet need, or unrecognized need on the basis of the child's use of post-acute services, the caregiver's report of unmet need, and the caregiver's report of the child's functioning as measured by the Pediatric Quality of Life Inventory (PedsQL). Regardless of the use of services or level of function, children of caregivers who reported an unmet need for a health care service were defined as having unmet need. Children who were categorized as having no needs were defined as those who did not receive services; whose caregiver did not report unmet need for a service; and the whose physical, socioemotional, and cognitive functioning was reported to be normal by the caregiver. Children with met needs were those who used services in a particular domain and whose caregivers did not report need for additional services. Finally, children with unrecognized needs were those whose caregiver reported cognitive, physical, or socioemotional dysfunction; who were not receiving services to address the dysfunction; and whose caregiver did not report unmet need for services. Polytomous logistic regression was used to model unmet and unrecognized need at 3 and 12 months after injury as a function of child, family, and injury characteristics. RESULTS. At 3 months after injury, 62% of the study sample reported receiving at least 1 outpatient health care service. Most frequently, children visited a doctor (56%) or a physical therapist (27%); however, 37% of caregivers reported that their child did not see a physician at all during the first year after injury. At 3 and 12 months after injury, 26% and 31% of children, respectively, had unmet/unrecognized health care needs. The most frequent type of unmet or unrecognized need was for cognitive services. The top 3 reasons for unmet need at 3 and 12 months were (1) not recommended by doctor (34% and 31%); (2) not recommended/provided by school (16% and 17%); and (3) cost too much (16% and 16%). Factors that were associated with unmet or unrecognized need changed over time. At 3 months after injury, the caregivers of children with a preexisting psychosocial condition were 3 times more likely to report unmet need compared with children who did not have one. Also, female caregivers were significantly more likely to report unmet need compared with male caregivers. Finally, the caregivers of children with Medicaid were almost 2 times more likely to report unmet need compared with children who were covered by commercial insurance. The only factor that was associated with unrecognized need at 3 months after injury was abnormal family functioning. At 12 months after injury, although TBI severity was not significant, children who sustained a major associated injury were 2 times more likely to report unmet need compared with children who did not. Consistent with the 3-month results, the caregivers of children with Medicaid were significantly more likely to report unmet needs at 1 year after injury. In addition to poor family functioning's being associated with unrecognized need, nonwhite children were significantly more likely to have unrecognized needs at 1 year compared with white children. CONCLUSIONS. A substantial proportion of children with TBI had unmet or unrecognized health care needs during the first year after injury. It is recommended that pediatricians be involved in the post-acute care follow-up of children with TBI to ensure that the injured child's needs are being addressed in a timely and appropriate manner. One of the recommendations that trauma center providers should make on hospital discharge is that the parent/primary caregiver schedule a visit with the child's pediatrician regardless of the post-acute services that the child may be receiving. Because unmet and unrecognized need was highest for cognitive services, it is important to screen for cognitive dysfunction in the primary care setting. Finally, because the health care needs of children with TBI change over time, it is important for pediatricians to monitor their recovery to ensure that children with TBI receive the services that they need to restore their health after injury.

Trisomy 18 and trisomy 13 are associated with serious and/or fatal birth defects, with death frequently occurring in the first month of life. Previous studies are limited by small samples and are dated. This study characterized the comorbid birth defects associated with trisomy 18 and trisomy 13 among US liveborn infants using the Healthcare Cost and Utilization Project's Kids' Inpatient Database and Nationwide Inpatient Sample, two large, current and nationally representative databases. The occurrence of 39 commonly reported comorbid birth defects among infants with trisomies 18 and 13 was compared to the occurrence of malformations among newborns without trisomies. The prevalences of trisomy 18 and 13 were 1.29/10,000 and 0.85/10,000 live births, respectively. Among infants with trisomy 18, 61% were female, 45.4% with heart defects. Among those with trisomy 13, 53% were female, 38.4% had heart defects, 24.5% had orofacial anomalies, and 11.2% had central nervous system abnormalities. More than half of the newborns with both conditions died prior to discharge. This updated information can be used to inform clinical decision-making and may help providers better prepare families for infants with trisomies.

Objective. All-terrain vehicle (ATV) injuries among children represent a significant and growing problem. Although state-level analyses have characterized some aspects of pediatric ATV-related injuries, little information on the national impact on hospitalization is available. This study was designed to characterize more fully the patterns of injury, hospital length of stay, and hospital charges associated with ATV-related injuries, with a nationally representative sample.Methods. Analyses were based on the 1997 and 2000 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The KID is the only national, all-payer database of hospital discharges for children. KID data were weighted to represent all discharges from general hospitals in the United States. Discharges with external cause-of-injury codes consistent with off-road ATV-related injuries were selected, and the affected population was described. Nationally representative rates of ATV-related injuries were calculated, and changes between 1997 and 2000 were documented.Results. An estimated 5292 children were hospitalized because of ATV-related injuries during the 2-year period, and hospitalizations increased 79.1% between 1997 and 2000. Rates of ATV-related hospitalization were highest among adolescent white male subjects, consistent with previous studies. Most patients had hospital lengths of stay of 8 days. Injury severity varied considerably, with more than one third of patients sustaining moderate to severe injuries. Approximately 1% of hospitalizations resulted in in-hospital deaths. Total hospital charges for this injury mechanism were $74367677 for the 2-year study period. Most of these charges were paid by private insurers.Conclusions. This study provides evidence supporting recent substantial increases in childhood ATV-related injuries. The hospitalization impact of ATV-related injuries among children is considerable. Our data support the need for ongoing creative attempts to identify effective strategies to decrease ATV injuries among children.

Objective. Injury is the major cause of death in children ages 1 to 19 in the United States and is a leading cause of morbidity. Few studies have described the impact of injuries on the health status of affected children over time or used newer, child-specific measures in this population. The objective of this study was to describe the health status of children in the 6 months after admission for injury using child-specific health status measures. Methods. Injured children who were ages 3 to 18 years and admitted to an academic children’s hospital were evaluated at discharge and at 1 and 6 months after discharge with a battery of outcome measures. The Child Health Questionnaire (CHQ) measured health status. The scores on the Functional Independence Measure (FIM) or pediatric version of the FIM tracked physical function. Results. A total of 195 children were enrolled. Boys outnumbered girls (67% vs 33%). Injury mechanisms and severity scores were typical of pediatric injury populations reported in other studies. Most (90%) children had at least 1 area of functional limitation by FIM at discharge, and 57% had some impairment at 1 month. By 6 months, 28% reported some limitation. At discharge, CHQ summary scores for the injury group were markedly depressed compared with normative populations. Differences in both physical health and psychosocial health summary scores between the injured and normal children persisted through 6 months of follow-up. Scores on 11 of 12 subscales were significantly below the normal population at discharge. This was particularly evident for bodily pain (injury group mean 49.1 vs normative mean 81.7) and parental impact-emotional (43.9 vs 80.3), and physical functioning (50.9 vs 96.1). Significant differences persisted in all subscales at 1 month and in 6 subscales at 6 months. Conclusions. The CHQ provided useful information about the impact of injuries on children and their families over time. Significantly reduced scores in several domains of the CHQ highlight problem areas for injury patients, several of which persist through 6 months of follow-up. Low scores in areas of bodily pain and parental emotional burden suggest that improved management of these problems is required. Additional study of risk factors for persistent problems after injury may suggest ways to improve functional outcomes of injured children and reduce the impact on their families.

This study was undertaken to examine variation in therapies and outcome for pediatric head trauma patients by patient characteristics and by pediatric intensive care unit. Specifically, the study was designed to examine severity of illness on admission to the pediatric intensive care unit, the therapies used during the pediatric intensive care unit stay, and patient outcomes.Consecutive admissions from three pediatric intensive care units were recorded prospectively (n = 5,749). For this study, all patients with an admitting diagnosis of head trauma were included (n = 477). Data collection occurred during an 18-month period beginning in June 1996. All of the pediatric intensive care units were located in children's hospitals, had residency and fellowship training programs, and were headed by a pediatric intensivist.Admission severity was measured as the worst recorded physiological derangement during the periodor=6 hrs before pediatric intensive care unit admission. Therapies and resource use were based on the Therapeutic Intervention Scoring System with adaptations for pediatrics. The use of intracranial pressure monitoring was recorded on admission to the unit (within 1 hr) and at any time during the pediatric intensive care unit stay. Outcomes were measured at the time of pediatric intensive care unit discharge by the Pediatric Overall Performance Category scale. Risk factors for mortality were examined by using bivariate analyses with significant predictors as candidate variables in a logistic regression to predict expected mortality. Intracranial pressure monitoring and other therapies were added to the mortality prediction model to test for protective effects. Finally, race and insurance status were added to the model to test for differences in the quality of care.The overall mortality rate for the entire sample was 7.8%. Mortality rates for childrenor=1 yr old were significantly higher than for children1 yr old (16.1% vs. 6.1%; p = .002). Comparisons by insurance status indicated that observed mortality rates were highest for self-paying patients. However, patient characteristics were not associated with use of therapies or standardized mortality rates after adjustment for patient severity. There was significant variation in the use of paralytic agents, seizure medications, induced hypothermia, and intracranial pressure monitoring on admission across the three pediatric intensive care units. In multivariate models, only the use of seizure medications was associated significantly with reduced mortality risk (odds ratio = 0.17; 95% confidence interval = 0.04-0.70; p = .014).Therapies and outcomes vary across pediatric intensive care units that care for children with head injuries. Increased use of seizure medications may be warranted based on data from this observational study. Large randomized controlled trials of seizure prophylaxis in children with head injury have not been conducted and are needed to confirm the findings presented here.

BACKGROUND: Graduated driver licensing (GDL) requirements aim to reduce the incidence of motor vehicle crashes and crash-related fatalities for novice drivers by limiting their exposure to the most risky driving situations. These programs vary across states in their scope, intensity, and impact. The purpose of this study was to evaluate the short-term impact of the 2009 Arkansas GDL on reducing teen crashes and fatal crashes. METHODS: Arkansas motor vehicle crash data for 2008 and 2010 were compared. Changes in rates per 10,000 licensed drivers were calculated by age, during the night restriction, and for drivers with passengers. χ analyses were used to test significant differences in rates between pre- and post-GDL years for each age group. RESULTS: Significant decreases in crash rates were found for each age group younger than 19 years, with the largest change evident for 16-year-olds (reduction of 22%). Similar decreases were not found for adults 19 years and older. Rates of fatal crashes for 14- to 18-year-olds were reduced 59%. Nighttime crashes and crashes in vehicles driven by teens with more than one unrelated passenger also demonstrated reductions. CONCLUSION: This study provides evidence of a short-term impact of GDL restrictions on reducing teen driver crashes and fatal crashes in Arkansas. Findings for teen drivers were significantly different from those of adult drivers during the same time frame, further strengthening the results as a function of GDL restrictions as compared with alternative explanations. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V. Language: en

BACKGROUND: The burden of all-terrain vehicle (ATV)-related injuries and deaths in the pediatric population has increased dramatically during the past decade. Brain injuries represent a large proportion of these injuries and are the leading cause of death among those injured. Despite the risk involved in operating these vehicles, helmet use remains low. The aim of this study was to identify and understand common barriers and facilitators to helmet use among ATV users. METHODS: Focus groups were conducted in Arkansas with adolescent and adult ATV users to discuss ATV and safety equipment use. Standard methods of qualitative research were used to interpret focus group data. Moderator guides were framed using the Health Belief Model of behavior change. Transcript-based analysis was used, and data were managed using HyperRESEARCH (version 2.8.3). The transcribed data were coded to identify important themes. RESULTS: Eleven focus groups were conducted with 58 participants, who discussed ATV use patterns, current safety practices, and barriers to helmet use. Major themes were a lack of perceived risk with operating an ATV and lack of perceived severity of injury resulting from ATV crashes. Participants discussed other barriers to helmet use including helmet discomfort and inconvenience. Suggested solutions included passage of helmet laws for riders younger than 18 years, helmet redesign, and development of visual aids/crash simulations to convey the dangers of ATV use. CONCLUSION: This study identifies a gap in risk perception among ATV users. Injury prevention should focus on education about risks of engaging in unsafe ATV behaviors and the danger of the vehicles themselves. Language: en

Study objectives: To describe the incidence of injuries associated with motorbike use in Bermuda and discuss prevention strategies. Methods: We conducted a population-based study of all incidents of traffic accidents involving motorbikes. Demographic characteristics and mechanisms, rates, and outcomes of injury for tourists and residents were compared. Results: We identified 657 cases of road trauma that occurred between July and September 1993. Of these cases, 538 (81.9%) involved motorbikes. The tourist rate of motorbike-related injury was 94.1/1,000 person-years at risk, whereas that of the local population was 16.6/1,000. The injury rate among residents was highest for young males, whereas among tourists it was highest among older persons. The relative risk (RR) of injury for tourists was 5.6 (95% confidence interval [CI], 4.8 to 6.7). Tourists also had an increased risk of fracture (RR, 1.43; 95% CI, 1.22 to 1.67). Conclusion: Tourists visiting Bermuda are at high risk of injury from motorbike use, with rates of injury much higher than the local population. Prevention strategies, particularly for older tourists, should be developed and implemented. [Carey MJ, Aitken ME: Motorbike injuries in Bermuda: A risk for tourists. Ann Emerg Med October 1996;28:424-429.]

An ATV (All-terrain vehicle) is a gasoline powered, fast moving off road vehicle often used for farming and industrial activities as well as recreational activities. The popularity of this type of vehicle has increased over the last decade with more than 10 million in use today. Most ATVs are designed for only single rider even though the seat of the ATV may appear big enough to carry a passenger. The presence of an additional person on a single person ATV greatly affects its dynamic handling characteristics. This change increases the risk of a crash and subsequent injuries to both riders. ATV crashes involving climbing and descending on steep hills are common. Lateral rollover crashes are often the result of riding an ATV at a high speed on uneven terrain. The presence of passenger on a single person ATV during these conditions changes the rider impact kinematics and resulting injury outcome, as the ATV behaves differently in the presence of an additional person. The computational model of a single person, adult-sized ATV, as developed previously for the study of child injury prevention, was used for this study. The multi-body computational model of this ATV was developed using biodynamic code MADYMO. This computational model was validated against the laboratory test for its dynamic and suspension characteristics. The tilt table test and the drop test were employed to compare the computational model result. This computer model was used to simulate the crash mechanism involving climbing and descending steep hills with two people on the ATV. This model was also used to simulate the lateral rollover of ATV with two people. The rider and the additional passenger on this single rider ATV were modeled using a 50th percentile male and a 5th percentile female. The two rider simulation was compared with single rider simulation for similar terrain and ATV speed to gain insight about the influence of this additional passenger weight on the crash kinematics of the ATV and the rider. These simulations will also be used in the future to generate more visually dramatic videos for educational intervention for ATV safety programs and other injury prevention activities.Copyright © 2012 by ASME

Background Child safety seats are known to reduce the risk of death from motor vehicle crashes by between 50%–80%. CSS use among younger children is common, use for older children is low, and CSS misuse is widespread. We developed a smart phone app to promote correct CSS use among children younger than 8 years old and tested it with parents of children who presented in one urban and one rural paediatric emergency department in 2 US states. Methods Research staff helped enrolled parents download the Safety in Seconds app to their smart phone. Parents completed a series of assessment items about their CSS knowledge and beliefs. Intervention group parents reported in more detail about their CSS beliefs and practices with all age-eligible children while control parents answered a similar number of items about another safety topic. Both groups received an electronic report from the app in real time that offered recommendations for improving their health behaviour of interest. All parents received periodic text messages and completed follow up reports through the app at 3 and 6 months. Study enrollment is expected to end in January 2016 and follow ups by July 2016. Results To date, 761 parents completed baseline surveys (32% rural; 68% urban). Study parents, on average, are black (65.6%), employed (65.8%), with more than a high school education (60.0%), with no differences between study groups. Index child is 5.2 years old. At 6 month follow up, more intervention group parents had gotten their child’s safety seat inspected by a car seat technician (34% vs 24%) and properly identified that children should ride in the back seat of the car until at least age 13 (35% vs 27%). Additional CSS knowledge, beliefs and practices will be explored when the final data set is ready. Conclusions Child passenger safety remains an important public health problem. Programs are needed to correct widespread misuse and to promote CSS use among older children.

BACKGROUND: Family-centered rounds (FCR) are defined as interdisciplinary bedside teaching rounds with active family participation. The objective of this study was to examine the association of FCR with family experiences and health services use. METHODS: Prospective study comparing families with a child admitted to general pediatric inpatient services with and without FCR. The presence of FCR elements was assessed before study enrollment. Study data were obtained by an in-person interview, a follow-up phone interview RESULTS: A total of 140 of 203 eligible families were enrolled; 97 completed follow-up surveys (49 on FCR team). Compared with non-FCR, FCR families were more likely to report consistent medical information (P < .001), the option of discussing care plan (P < .001), doctors listening carefully (P < .01), and doctors showing respect (P < .001). No differences were found in number of medications (mean 2.4 vs 2.9, P = .26) or discharge time (mean 3:06 pm versus 2:43 pm, P = .39). No difference was found for hospital charges after adjusting for length of stay outliers. CONCLUSIONS: FCR are associated with higher parent satisfaction, consistent medical information, and care plan discussion, with no additional burden to health service use. Additional studies should assess FCR under different settings of care.

BACKGROUND:In the United States, drowning is the second leading cause of unintentional injury death in children aged 1 to 19 years, accounting for nearly 1100 deaths per year. Although a decline in overall fatal drowning deaths among children has been noted, national trends and disparities in pediatric drowning hospitalizations have not been reported.METHODS:To describe trends in pediatric drowning in the United States and provide national benchmarks for state and regional comparisons, we analyzed existing data (1993–2008) from the Nationwide Inpatient Sample, the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0 to 19 years were included. Annual rates of drowning-related hospitalizations were determined, stratified by age, gender, and outcome.RESULTS:From 1993 to 2008, the estimated annual incidence rate of pediatric hospitalizations associated with drowning declined 49% from 4.7 to 2.4 per 100 000 (P < .001). The rates declined for all age groups and for both males and females. The hospitalization rate for males remained consistently greater than for females at each point in time. Rates of fatal drowning hospitalization declined from 0.5 (95% confidence interval, 0.4–0.7) deaths per 100 000 in 1993–1994 to 0.3 (95% confidence interval, 0.2–0.4) in 2007–2008 (P < .01). No difference was observed in the mean hospital length of stay over time.CONCLUSIONS:Pediatric hospitalization rates for drowning have decreased over the past 16 years. Our study provides national estimates of pediatric drowning hospitalization that can be used as benchmarks to target and assess prevention strategies.

Objectives. We compared state-specific all-terrain vehicle (ATV) fatality rates from 2000–2007 with 1990–1999 data, grouping states according to helmet, training, and licensure requirements. Methods. We used the CDC WONDER online database to identify ATV cases from 2000–2007 and calculate rates per 100,000 population by state, gender, and age. Results. ATV deaths ( n=7,231) occurred at a rate of 0.32 per 100,000 population. Males accounted for 86% of ATV-related deaths at a rate that was six times that for females (0.55 vs. 0.09 per 100,000 population, respectively); 60% of the male deaths occurred in the 15- to 44-year age group. With the exception of the two oldest age categories, rates were consistently higher in the no-helmet-law group. Both the number and rate of ATV-related deaths increased more than threefold between 1990–1999 and 2000–2007. West Virginia and Alaska continue to have the highest ATV fatality rates (1.63 and 2.67 ATV deaths per 100,000 population, respectively). Conclusions. Helmet-use requirements seem to slightly mitigate ATV-related death, but training requirements do not. For policy to be effective, it must be enforced.

Background Millions of all-terrain vehicles (ATV) are used around the world for recreation by both adults and youth. This increase in use has led to a substantial increase in the number of injuries and fatalities each year. Effective strategies for reducing this incidence are clearly needed; however, minimal research exists regarding effective educational interventions. Objective This study was designed to assess rural ATV riders9 preferences for and assessment of safety messages. Methods 13 focus group discussions with youth and adult ATV riders were conducted. 88 formative research participants provided feedback on existing ATV safety materials, which was used to develop more useful ATV safety messages. 60 evaluative focus group participants critiqued the materials developed for this project. Results Existing ATV safety materials have limited effectiveness, in part because they may not address the content or design needs of the target population. ATV riders want educational and action-oriented safety messages that inform youth and adult riders about their responsibilities to learn, educate and implement safety behaviours (eg, appropriate-sized ATV, safety gear, solo riding, speed limits, riding locations). In addition, messages should be clear, realistic, visually appealing and easily accessible. Newly designed ATV safety materials using the acronym TRIPSS (training, ride off-road, impairment, plan ahead, safety gear, single rider) meet ATV riders9 safety messaging needs. Conclusions To reach a target population, it is crucial to include them in the development and assessment of safety messages. Germane to this particular study, ATV riders provided essential information for creating useful ATV safety materials.

Emergency department (ED) crowding is an increasingly common problem in the United States. Crowding can lead to ED closure and diversion, poor patient satisfaction, and patient safety issues. The purpose of this study was to examine measures of ED census and measures of crowding to determine if a correlation exists in a pediatric ED setting.Arkansas Children's Hospital is a major pediatric referral center. Measures of ED acuity (including total census, admission rate, total number of admissions, and proportion of triage category nonurgent patients) and measures of throughput (left-without-being-seen [LWBS] rate and ED length of stay [LOS]) data for 11 years (1996-2006) were plotted, and correlation coefficients were calculated.Annual ED census varied between 35,415 and 40,711 during the 11-year study period. The total number of admissions increased from 4179 in 1996 to 6539 in 2006. When total census was plotted against LWBS rate and ED LOS, a poor correlation was found (R² = 0.007 for total census vs LWBS rate). However, a strong correlation was found when the relationship between the total number of admissions and LWBS rate was examined (R² = 0.89). Similarly, a strong relationship between the admission rate and LWBS rate was seen (R² = 0.75). In addition, a strong correlation was seen between admissions (total and percentage) versus ED LOS.There is a strong correlation between the number of patients admitted and measures of overcrowding in this pediatric ED, but there is a poor correlation between the total census and overcrowding measures. Targeting process improvement on hospital-wide patient flow may help reduce ED crowding.

In the United States, burns are the third leading cause of unintentional injury death in children aged 1-14 years, accounting for more than 600 deaths per year in children aged 0-19 years.To describe trends in paediatric burn hospitalisations in the United States and provide national benchmarks for state and regional comparisons.Analysis of existing data (1993-2006) from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0-19 years were included.Estimated national annual rates of burn-related hospitalisations, stratified by age, gender, and in-hospital mortality.From 1993 to 2006, the estimated annual incidence rate of paediatric hospitalisations associated with burns declined 40% from 27.3 (1993-94) to 16.1 per 100,000 (p0.001). The rates declined for all age groups and for both boys and girls. Boys were consistently more likely to be hospitalised than girls (20.3 vs 11.7 hospitalisations per 100,000 during 2004-06, p0.001). For children less than 5 years of age, burn hospitalisations decreased 46% from 65.2 per 100,000 in 1993-94 to 35.1 per 100,000 in 2004-06 (p0.001). Fatal hospitalisation rates also declined from 0.3 deaths per 100,000 in 1993-94 to 0.1 in 2004-06 (p0.001).Paediatric hospitalisation rates for burns have decreased over the past 14 years. The study also provides national estimates of paediatric burn hospitalisations that can be used as benchmarks to further injury prevention effectiveness through targeting of effective strategies.

Better insights into ATV crash mechanisms are needed to facilitate effective prevention strategies. Rollover crashes and resulting injuries represent major problems associated with ATVs. These problems are aggravated with the rider is a young child, since all ATVs are rider active machines. Serious injuries associated with child use of adult ATVs are an increasing problem in the United States and other countries. The computational technique is used to develop a detailed adult size ATV. The computational model is developed using the biodynamic code MADYMO. Laboratory tests are conducted on the ATV to extract the dynamic characteristics of the ATV. The ATV model developed features a detailed suspension system. The computational model confidence is increased using a digitized surface to create the rigid body model. The computational ATV model is validated for its lateral stability using a laboratory tilt table test. The suspension system is validated using a drop test on a rigid floor. This validated model is used to simulate and understand crashes and parameters affecting the injury outcome. A Hybrid III six year old dummy is used during the laboratory tilt table test and for initial crash simulations. This paper demonstrates the methodology used to develop a crash analysis for an ATV driven by a six year old child. The computation model is used to recreate a forward flip rollover crash scenario.Copyright © 2011 by ASME

Wide variation has been reported in the proportion of injury deaths occurring during the prehospital phase. Potential disparities in where injured people with epilepsy and seizure disorders die have not been examined. We compared location of death between injured patients with epilepsy and seizure disorders and similar patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy/seizures are more likely to die outside of a hospital or health care setting.U.S. vital statistics (mortality) data from the multiple cause of death files of the National Center for Health Statistics were analyzed. Patients less than 65 years of age at death who had injury as the underlying cause of death were included. Multinomial logistic regression was used to assess location of death, controlling for patient and injury characteristics.Controlling for potential confounders, people with epilepsy/seizures were more likely to die at home from unintentional injuries (relative risk ratio [RRR]=1.51, P0.001) and less likely to die in public places (RRR=0.27, P0.001). People with epilepsy/seizures were less likely to die at home or in public places from suicide, but significantly more likely to die at home from homicide (RRR=2.29, P0.001). By mechanism of injury, people with epilepsy/seizures were more likely to die at home from drowning (RRR=2.35, P0.001).Disparities in where injured people with epilepsy/seizures die deserve further attention. Identifying the underlying causes of these disparities will allow for the development of targeted prevention interventions.

Objective.We determined the rate and costs of recent U.S. all-terrain vehicle (ATV) and bicycle deaths.Methods.Fatalities were identified from the National Center for Health Statistics Multiple Cause-of-Death public-access file. ATV and bicycle deaths were defined by International Classification of Diseases, 10th Revision codes V86.0–V86.9 and V10–V19, respectively. Lifetime costs were estimated using standard methods such as those used by the National Highway Traffic Safety Administration.Results.From 2000 through 2005, 5,204 people died from ATV crashes and 4,924 from bicycle mishaps. A mean of 694 adults and 174 children died annually from ATV injuries, while 666 adults and 155 children died from bicycle injuries. Death rates increased among adult ATV and bike riders and child ATV riders. Males had higher fatality rates for both ATVs and bicycles. Among children, total costs increased 15% for ATV deaths and decreased 23% for bicycle deaths. In adults, ATV costs increased 45% and bike costs increased 39%.Conclusions.Bicycle- and ATV-related deaths and associated costs are high and, for the most part, increasing. Promotion of proven prevention strategies, including helmet use, is indicated. However, enforcement of helmet laws is problematic, which may contribute to observed trends.

Although helmet use has been shown to be effective in reducing traumatic brain injuries (TBIs) due to motorcycle and bicycle crashes, it is unknown whether helmet use is associated with different injury patterns and severity for users of all-terrain vehicles (ATVs).To compare likelihood of injury and death between helmeted and unhelmeted riders of ATVs.The National Trauma Data Bank for years 2002-2006 was used to examine the records of 11 589 patients hospitalized for injuries resulting from ATV use. The likelihood of receiving a TBI diagnosis or a significant injury to other body regions and differences in injury severity and in-hospital mortality between helmeted and unhelmeted ATV riders were compared.After multivariable adjustment, compared with helmeted riders, unhelmeted riders were significantly more likely to sustain any TBI (OR 1.62, 95% CI 1.49 to 1.76, p0.001) and major/severe TBI (OR 3.19, 95% CI 2.39 to 4.25, p0.001). Unhelmeted riders were significantly more likely to die while in hospital than were helmeted riders (OR 2.58, 95% CI 1.79 to 3.71, p0.001). Significant injuries to the neck and face regions were also significantly more likely in unhelmeted riders (OR 3.53, 95% CI 1.28 to 9.71, p = 0.015, and OR 1.94, 95% CI 1.32 to 2.84, p = 0.001, respectively).ATV riders who do not wear helmets are more likely to receive significant injuries to the head, face, and neck. Prevention strategies and enforceable policy interventions to increase helmet use among ATV riders appear warranted.

OBJECTIVE. Traumatic brain injury has a substantial impact on caregivers. This study describes the burden experienced by caregivers of children with traumatic brain injury and examines the relationship between child functioning and family burden during the first year after injury.PATIENTS AND METHODS. Children aged 5 to 15 years hospitalized for traumatic brain injury at 4 participating trauma centers were eligible. Caregivers completed baseline and 3- and 12-month telephone interviews measuring the child's health-related quality of life using the Pediatric Quality of Life Inventory. The emotional impact scale of the Child Health Questionnaire was used to identify caregivers with substantial distress, including general worry or interference with family routine. Caregiver perceptions of whether health care needs were met or unmet and days missed from work were also measured.RESULTS. A total of 330 subjects enrolled; follow-up was conducted with 312 at 3 months and 288 at 12 months. Most subjects were white (68%) and male (69%). Abnormal Pediatric Quality of Life Inventory subscores were related to substantial caregiver burden (either general worry or interference in routine). These abnormalities were reported by >75% of patients at 3 months and persisted to 1 year in some patients. Parental perception of unmet health care needs was strongly related to family burden outcomes, with up to 69% of this subset of parents reporting substantial worry, and nearly one quarter reporting interference with daily routine/concentration 1 year after injury. Child dysfunction predicted parental burden at 3 and 12 months. Burden was greater when health care need was unmet. Abnormalities on the Pediatric Quality of Life Inventory predicted the amount of work missed by parents, especially in the presence of unmet needs.CONCLUSIONS. Caregivers are more likely to report family burden problems when child functioning is poorer and health care needs are unmet. Improved identification and provision of services is a potentially modifiable factor that may decrease family burden after pediatric traumatic brain injury.

OBJECTIVES. The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons. METHODS. Analysis of existing data (1991–2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined. RESULTS. From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100 000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100 000 in 1991–1993 to 2.8 deaths per 100 000 in 2003–2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged. CONCLUSIONS. Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.

Substantial variation exists with respect to the management of traumatic brain injuries (TBI) in children. Centers that practice aggressive treatment of TBI may improve survival, but it is not clear that the outcomes can be justified using cost-effectiveness criteria. This study illustrates the use of cost-effectiveness analysis to assess interventions for improving outcomes in children by assessing the cost per quality-adjusted life year (QALY) gained from technological change in the treatment of TBI. Cost and survival data associated with technological change in the treatment of pediatric TBI was based on nationally representative hospital administrative data for all children