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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.

Firearms contribute substantially to leading causes of death among US children ages 10-19 (suicide and homicide). Safe storage of guns is important but poorly adopted. This study sought to understand knowledge, attitudes, beliefs, and firearm storage practices among parents living in households with firearms. Focus groups (FG) were conducted with gun-owning parents/guardians in three US states with high firearm ownership. Participants also completed an anonymous survey which included demographic characteristics, previous gun education, purpose of gun ownership, and storage practices. Eight FG were conducted with 57 parents. 74% of participants stored at least one firearm unlocked, with many loaded. Overall risk perception for firearm injury was low. Many participants believed modeling responsible use within the family would demystify the presence of a firearm and decrease accidental shootings. There was strong perception that safe storage interferes with personal protection needs, especially for handguns. Trigger locks were considered a nuisance and rarely used. Parents were confident in their youth's ability to handle guns safely and did not believe that safe storage would deter suicide. Preferred messengers for safe storage education were military or law enforcement rather than physicians. Participants advocated for safe storage education paired with hands-on use education. Gun-owning parents supported safety education and endorsed education from nonmedical sources. Education about suicide prevention may improve adoption of safe storage by parents. These results will inform the development of a firearm safe storage campaign with improved acceptability for communities with high firearms use and ownership.

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.

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.

Purpose Safety in Seconds (SIS) is a smartphone app that has demonstrated effectiveness at changing injury prevention behaviors. The aim of this analysis was to understand how parents engaged with each component of the app and determine if there was an association between app usage and behaviors. Methods Parents of children aged 4–7 visiting the pediatric emergency room in the two participating sites (regardless of the reason for the visit) were recruited. Study participants downloaded the SIS app onto their smartphone and were randomized receive car seat or fire safety information. Both groups completed a 10-minute assessment about their safety knowledge and behaviors 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 Among the 602 parents completing all follow up points, 37% visited each page of the report, 19% emailed the report to themselves or someone else, and 33% visited the Parent Portal. Among 555 parents reporting at least one unsafe behavior at baseline, 130 (23.5%) changed their safety behaviors and reported no unsafe behaviors at the 6-month follow up. Those changing their behavior had more mean clicks (24 vs. 18; p Conclusion Smartphone applications hold potential for changing behaviors that are known to improve child passenger safety.

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

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.

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

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.

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.

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.

Purpose: All-terrain vehicle (ATV) injury is an increasingly serious problem, particularly among rural youth. There have been repeated calls for ATV safety education, but little study regarding optimal methods or content for such education. The purpose of this study was to determine if an ATV safety video was effective in increasing ATV safety knowledge when used in a community-based statewide hunter education program. Methods: During the baseline phase, surveys focusing on ATV safety were distributed to students in the Arkansas hunter safety program in 2006. In the intervention phase a year later, an ATV safety video on DVD was provided for use in required hunter education courses across Arkansas. The same survey was administered to hunter education students before and after the course. Findings: In the baseline phase, 1,641 precourse and 1,374 postcourse surveys were returned and analyzed. In the intervention phase, 708 precourse and 694 postcourse surveys were completed. Student knowledge of ATV safety after watching the video was higher than in preintervention classes. Knowledge of appropriate helmet usage increased from 95% to 98.8% (P Language: en

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.

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. 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.

Aitken ME, Mele N, Barrett KW. Recovery of injured children: parent perspectives on family needs. Arch Phys Med Rehabil 2004;85:567–73. Objective To study the broader impact of emotional and financial burdens of injury in children on their families, along with solutions to these problems. Design Focus groups were conducted to reveal the needs of parents and children after injury. Audiotaped semistructured interviews were conducted by a team of qualitative researchers. Setting Tertiary care children's hospital. Participants Mothers of children who had sustained traumatic injury. Interventions Not applicable. Main outcome measures Summary of reported themes of experience and suggested interventions. Data were analyzed by using content analysis software. Results Overall satisfaction with care was high. Parents expressed concerns with communication, access to care, and the transition both within the phases of medical care and from medical care into the community. Consistent financial and social stressors were voiced, along with the need for peer support during all phases of care. Conclusions Parents provided valuable insight into their needs after their child's injury. Attention to constructive communication, clarification of the system of care, continued family-centered care, and development of peer support programs may meet the needs of caregivers and therefore facilitate improvement in pediatric injury recovery.

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.

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.]

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.

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.

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

Cost-effectiveness analysis relies on preference-weighted health outcome measures as they form the basis for quality adjusted life years. Studies of preference-weighted outcomes for children following traumatic brain injury are lacking.This study seeks to describe the preference-weighted health outcomes of children following a traumatic brain injury at 3- and 6-months following pediatric intensive care unit (ICU) discharge.Children aged 5-17 who required ICU admission and endotracheal intubation or mechanical ventilation.The Quality of Well-being (QWB) score was used to describe preference-weighted outcomes. Clinical measures from the intensive care unit stay were used to estimate risk of mortality. Risk of mortality, Glasgow coma scores, patient length of stay in the intensive care unit, and parent-reported items from the Child Health Questionnaire (CHQ) were used to test construct validity.Subject data were obtained from nine pediatric intensive care units with consent procedures approved by representative institutional review boards. Medical records containing clinical information from the ICU stay were abstracted by the study coordinating center. Caregivers of children were contacted by telephone for follow-up interviews at 3- and 6-months following ICU discharge. All interviews were conducted by telephone with the primary caregiver of the injured child. Preference score statistics are presented overall and in relation to characteristics of the patient and their ICU admission.A response rate of 59% was achieved for the 3-month interviews (N = 56) and 67% for the 6-month interviews (N = 65) for caregivers of children aged 5 years and above that consented to participate. Overall, QWB scores averaged 0.508 (95% CI: 0.454-0.562) at the 3-month interview and 0.582 (95% CI: 0.526-0.639) at the 6-month interview. For both interview periods, scores ranged from 0.093 to 1.0 on a 0-1 value scale, where 0 represents death and 1 represents perfect health. Specific acute and chronic health problems from the QWB scale were present more often in patients with higher injury severity. Mortality risk, ICU length of stay, Glasgow Coma Scales, and parental reported summary scores from the CHQ all correlated correctly with the QWB scores.The findings support the use of the QWB score with parental report to measure preference-weighted health outcomes of children following a traumatic brain injury. Information from the study can be used in economic evaluations of interventions to prevent or treat traumatic brain injuries in children.

Objective Families with young children are at increased risk for home fires. Fire departments have used a number of approaches to increase the uptake of smoke alarms in high-risk homes with mixed success. This presentation will describe a pilot study that partnered a nurse home visiting program for high-risk, low-income families with a local fire department in Phoenix, AZ to instal smoke alarms. Methods During a regularly scheduled home visit, nurses with the Nurse-Family Partnership (NFP) at the Maricopa County Department of Public Health informed their clients about an opportunity to have smoke alarms installed in their home. Nurses sent a referral to the Phoenix Fire Department (PFD) for a free smoke alarm installation for free. PFD volunteers accompanied nurses during a following appointment to instal smoke alarms and to provide safety education. Mixed Methods were used for the evaluation, including a 3-month follow-up survey of knowledge, observation of smoke alarms, and in-depth interviews with key informants from NFP and PFD. Results 58 clients enrolled in the pilot study. To date, 41 smoke alarm installation visits and 33 follow-up surveys have been completed. Before the program, 56% (n = 23/41) of homes had no working smoke alarm. PFD installed 54 smoke alarms into 41 homes; every home had at least one smoke alarm by the end of the home visit. At follow-up, all homes maintained at least one smoke alarm. Clients increased knowledge scores by 30%. Interviewees from both NFP and PFD spoke highly of the program, found it to be consistent with their organisations’ missions, and would like it to continue. Final analyses of the full sample of follow-ups and of the qualitative interviews will be presented. Conclusion Pairing home visiting nurses with local fire departments can be a successful approach to increasing the number of high-risk homes with smoke alarms.

OBJECTIVES: Clothesline injury to the face and neck is a unique mechanism of injury seen in children and adolescents on all-terrain vehicles (ATVs). The purpose of this study was to describe this serious and avoidable injury pattern. METHODS: A search was made of the trauma registry at a major pediatric referral hospital for the years 1998 to 2003 to find cases of clothesline injury associated with ATV use. The data were deidentified and compiled by the research group. The study was deemed exempt by the local institutional review board. RESULTS: Seven cases of neck and/or facial injury were found associated with a child or adolescent on an ATV striking a wire fence or clothesline. All patients were white, including 5 boys and 2 girls. The mean age was 8 years (range, 2-14 years). In most cases (5/7), the child was driving across a field when the wire fence was struck. All patients had significant neck and/or facial lacerations, and 5 of 7 patients were taken to the operating room for wound closure. One patient had functional impairment, and all had lasting disfigurement. The mean initial hospital charges were US22,843 dollars. CONCLUSIONS: Clothesline injury to the neck and face associated with ATV use in children and adolescents is a unique and serious injury mechanism. Because all of these injuries in our series occurred in young children or adolescents who were driving or riding on the front of the ATV, it emphasizes the recommendation that children and young adolescents should not ride or drive ATVs.

OBJECTIVE: This study examines the incidence, utilization of procedures, and outcomes for critically ill children hospitalized with traumatic brain injury over the period 1988-1999 to describe the benefits of improved treatment. DESIGN: Retrospective analysis of hospital discharges was conducted using data from the Health Care Cost and Utilization Project Nationwide Inpatient Sample that approximates a 20% sample of U.S. acute care hospitals. SETTING: Hospital inpatient stays from all types of U.S. community hospitals. PARTICIPANTS: The study sample included all children aged 0-21 with a primary or secondary ICD-9-CM diagnosis code for traumatic brain injury and a procedure code for either endotracheal intubation or mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deaths occurring during hospitalization were used to calculate mortality rates. Use of intracranial pressure monitoring and surgical openings of the skull were investigated as markers for the aggressiveness of treatment. Patients were further classified by insurance status, household income, and hospital characteristics. Over the 12-yr study period, mortality rates decreased 8 percentage points whereas utilization of intracranial pressure monitoring increased by 11 percentage points. The trend toward more aggressive management of traumatic brain injury corresponded with improved hospital outcomes over time. Lack of insurance was associated with vastly worse outcomes. An estimated 6,437 children survived their traumatic brain injury hospitalization because of improved treatment, and 1,418 children died because of increased mortality risk associated with being uninsured. Improved treatment was valued at approximately dollar 17 billion, whereas acute care hospitalization costs increased by dollar 1.5 billion (in constant 2000 dollars). Increased mortality in uninsured children was associated with a dollar 3.76 billion loss in economic benefits. CONCLUSIONS: More aggressive management of pediatric traumatic brain injury appears to have contributed to reduced mortality rates over time and saved thousands of lives. Additional lives could be saved if mortality rates could be equalized between insured and uninsured children.

A 3-year project was undertaken to evaluate two methods of promoting residential smoke alarm installation and maintenance in high risk households across the U.S. Five states (Arkansas, Maine, Maryland, Massachusetts, and North Carolina) participated. The two strategies under study were direct installation of smoke alarms and distribution of a voucher for free smoke alarms. The target population included occupants of high-risk households without working smoke alarms who were approached as part of a door-to-door canvassing program. Fire Safety education was provided to both groups. A follow up assessment conducted 6-12 months post intervention assessed the presence and functional status of smoke alarms in each of the two groups. Demographic and fire safety data were also collected at baseline and follow up for each group. 4,455 households were enrolled in the study [Installation Group: 2,206 (49.5%), Voucher Group: 2,249 (50.5%)]. Baseline characteristics of the groups within each state were comparable. Follow up data was obtained on 1,583 installation group households and 1,545 voucher group households. At follow up, 1,421 (89.8%) households in the installation group had working smoke alarms, compared with 997 (65%) households in the voucher group, Odds Ratio 4.82 (95% CI=3.97, 5.85) (p

Objective: A variety of educational efforts, policies, and regulations have been adopted to reduce all-terrain vehicle (ATV) injury in children. Despite this, ATV use by children continues and serious injuries are common. The purpose of this study was to investigate the knowledge, practices, and beliefs of ATV users to help develop effective educational strategies to promote safer ATV use. Design: Focus groups were conducted to characterize participant ATV use and safety awareness as well as to explore avenues for prevention. Feedback on draft ATV safety public service announcements was elicited. Themes of transcribed focus group data were summarized. Setting: Rural state with high ATV use and injury rates. Subjects: Adult and adolescent ATV users. Interventions: None. Main outcome measures: Summaries of focus group discussions. Results: ATV riders frankly discussed current use and safety behaviors and were aware of some ATV risks. Youths felt that age specific regulation was unlikely to be a helpful strategy. Participants endorsed messages demonstrating graphic consequences as likely to get the attention of young riders regarding risks. Educational settings were suggested, including hunter and driver safety classes. Conclusions: Efforts to improve ATV safety awareness should clearly show pediatric ATV injury risk and safety practices. Campaigns must also show realistic understanding of current use practices to be credible for users. Messages emphasizing the consequences of ATV use were endorsed as most likely to have impact. Approaches based on age based restrictions were considered unrealistic and alternative strategies were suggested.

Objective: To assess functional outcome and describe disability at discharge in children who have had trauma without significant head injury. Design: Retrospective cohort. Setting: National Pediatric Trauma Registry, 1988–1994. Participants: Patients of ages 7 to 18 years with Glasgow Coma Scale (GCS) 13 to 15 without significant anatomic head injury. Results: Functional Independence Measure (FIM) at discharge was used to assess patient outcome. There were 13,649 children meeting study criteria who had sustained 34,254 injuries. Fractures constituted 30% of all injuries. As measured by FIM, 1,522 (11.2%) patients had mild disability at discharge; 1,983 (14.5%) had moderate disability. After adjustment for age and injury severity, children with lower extremity fractures were more likely to be discharged with functional limitations than those without (relative risk, 5.43; 95% confidence interval: 5.06, 5.84). Of children with moderate disability at discharge, less than 50% were referred for rehabilitation evaluation and less than 25% for physical therapy. Conclusion: Functional dependence is present in a large proportion of injured children, even without significant head injury. Rehabilitation and other services may be underused in this population. Further study is required to fully assess the degree and duration of disability in these patients.

Introduction All terrain vehicle (ATV) injuries are increasing among rural children and adolescents. Methods to effectively promote ATV safety messages are not well described. The purpose of this study was to determine the feasibility of using a movie theatre as a venue for ATV injury prevention. Methods A public service announcement on ATV safety was shown in a rural movie theatre in Arkansas, USA, for a period of 8 weeks in the summer, 2009. Patrons were asked to complete exit surveys by trained volunteers. The survey tested the recall of messages in the movie previews, including the ATV announcement. χ 2 was used to determine statistical significance. Results 703 movie patrons completed the survey; 508 reported arriving in the theatre before the previews started and 195 reported arriving after the previews. Of those arriving before the previews, 75% recalled an ATV safety message versus. 23% of those who arrived after the previews (p Conclusions This trial demonstrated that an ATV safety message shown in a rural movie theatre is associated with rates of recall higher than commercial advertising shown in the same preview and is associated with high rates of agreement with the primary safety message. This strategy may be effective in spreading injury prevention messages.

Introduction/objective Persons living in rural areas are at great risk of motor vehicle injury, as are children ages 4–7 years when prematurely graduated to seat belts designed for adults. Social marketing, individual decision-making and community engagement models were integrated to increase booster seat use through an accepted sport in rural communities. We report on lessons learnt from a multi-state study in the USA. Methods A non-randomised controlled design was used. Intervention strategies included building child passenger safety resources, tailored print media, community presentations and local spokespersons. Restraint was assessed for all children Results Twenty rural communities participated. Community members were engaged at every site to increase community access. Study communities with pre-existing child restraint resources were less engaged in planning and implementation than communities with few resources. Participation from parents varied according to buy-in from team coaches. Frequent communication and a personal presence in the study communities were critical factors to participation and interest. Weather and unanticipated events competing for community interests occurred. The project increased capacity and resources for sustained child passenger safety efforts in engaged communities. Conclusions The study was successful in generating local support and resources for child restraint. Flexibility and personal connections with local leaders increased volunteer recruitment and community involvement. Efforts are ongoing to sustain community interest.