Search

Background The Resident Education in Advocacy and Child Health (REACH) pathway at a large academic pediatric residency program in the Northwest includes an academic-community partnership in a rural community. Few academic-community partnership evaluations have focused on community values. REACH trainees conducted a 5-year evaluation of the partnership using community-generated outcomes measures. We sought to 1) apply community-based participatory research (CBPR) principles to engage community stakeholders, 2) mutually develop program evaluation measures, and 3) describe core projects and the community's perceptions of the REACH program. A secondary objective was to evaluate REACH pathway influence on trainee alumni. Methods We used a community-informed design to determine outcomes and indicators, 2) gathered data through iterative review of materials, stakeholder interviews, and alumni surveys, and 3) conducted a quantitative and qualitative analysis and synthesis. Results Four short-term outcomes measures were identified for a logic model: 1) project sustainability, 2) direct engagement with youth, 3) Community partnerships, and 4) "ripple effects." Of non-foundational projects, 50% were sustained at the time of the evaluation. Fourteen projects (70%) engaged youth. At least five ongoing community partnerships were identified. Four stakeholders (24%) noted a ripple effect. Trainee alumni reported increased confidence in research skills, cultural competence, and appreciation of community perspectives. Key themes of the partnership's value were relationships, outsider perspective and professional expertise, trainees as catalyst, and balance of research with action. Conclusions Our evaluation demonstrated the partnership's value to community and trainees and yielded suggestions for increasing the program's impact. We believe that key elements of this evaluation could be used in other academic-community partnership programs.

Hemorrhagic pneumonia (HP) is a rare but highly lethal disease, mainly of dogs and cats, caused by hemolytic Escherichia coli strains that contain cnf1 (encoding cytotoxic necrotizing factor 1). After encountering fatal HP in two dogs, we used contemporary molecular methods, including multi-locus sequence typing and whole genome sequencing, to compare the corresponding case isolates with published HP clinical isolates and newly-obtained fecal E. coli isolates from 20 humans and animals in the index HP case household. We also compared the aggregated HP clinical isolates, which represented 13 discrete strains, by pulsotype with a large, private pulsotype library of diverse-source E. coli. The HP clinical isolates represented a narrow range of phylogenetic group B2 lineages (mainly sequence types 12 and 127), O types (mainly O4 and O6), and H types (mainly H5 and H31), but diverse fimH alleles (type-1 fimbriae adhesin). Their extensive, highly conserved virulence genotypes, which qualified as extraintestinal pathogenic E. coli (ExPEC), encoded diverse adhesins, toxins, iron uptake systems, and protectins. Household surveillance identified multiple HP-like fecal strains, plus abundant between-host strain sharing, including of the household's index HP strain. The pulsotype library search identified, for five HP clinical strains, same-pulsotype human and animal fecal and clinical (predominantly urine) isolates, from diverse locales and time periods. Thus, E. coli strains that cause HP derive from a narrow range of ExPEC lineages within phylogroup B2, contain multiple virulence genes other than cnf1, are shared extensively between hosts, and likely function in nature mainly as intestinal colonizers and uropathogens. Importance This study clarifies the clonal background and extensive virulence genotypes of the E. coli strains that cause hemorrhagic pneumonia in domestic animals (mainly dogs and cats), shows that such strains circulate among animals and humans, identifies a substantial intestinal colonization component to their lifestyle, and extends their known clinical manifestations to include bacteremia and urinary tract infection. The findings place these strains better into context vis-a-vis current understandings of E. coli phylogeny, ecology, and pathogenesis; identify questions for future research; and may prove relevant for surveillance and prevention efforts.

We explore whether the timing and burden of paediatric window fall injuries in the Seattle area have changed with higher temperatures and increased air conditioning (AC) prevalence. Using hospital trauma registry records from 2005 to 2017, along with population estimates from the National Center for Health Statistics, we calculate trauma incidence rates from paediatric window falls. Using local temperature data, we explore the relationship between temperature increases over time and the seasonality and rate of incidents. Window falls are a substantial cause of injury among children, with an annual trauma incidence rate among children age 0–8 of 10.4 per 100 000 boys and 5.9 per 100 000 girls in our sample. We find a mildly positive trend in the crude rate of window falls over the study period, increasing further when a population-level adjustment for AC prevalence is included. We do not find evidence of earlier injury timing during the calendar year.

Objective To assess the feasibility and acceptability of a telephone-based education and navigation program for Hispanic parents of children hospitalized with traumatic brain injury (TBI). Setting Level I trauma hospital and pediatric inpatient rehabilitation unit in the Northwestern United States. Participants Fourteen Hispanic parent-child dyads. Parents were 85% female, with a mean age of 35 years. Children were 58% male, with a mean age of 9.7 years, and had been hospitalized for complicated mild/moderate (n = 5) or severe (n = 9) TBI. Design Pilot prospective cohort design. Main measures Feasibility measures include recruitment, retention, and intervention adherence rates. Acceptability of intervention was measured by parents' use of educational materials and satisfaction with navigation program. We also evaluated study processes, including completion of baseline, 3, 6, and 12 months functional assessments of the child; assessment of parental health literacy and self-efficacy; and adherence to follow-up rehabilitation appointments. Results Eighty-two percent of approached potential participants were recruited into the study. One hundred percent of participants completed the intervention, and 85% had 1-year follow-up. Intervention acceptability was high: 90% reported satisfaction with navigator, and 92% used the educational manual. Assessments demonstrated significant improvement in parents' TBI caregiving and community self-efficacy; 92% attendance to follow-up rehabilitation appointments; and improvement in the child's functional measures, except communication skills. Conclusions Findings support feasibility and acceptability of a culturally relevant program to facilitate transitions of care for Hispanic children with TBI. A future randomized trial is warranted to determine the efficacy of the intervention on long-term treatment adherence and the child's post-TBI function.

As far as we know, there are no tested in-hospital care programmes for paediatric traumatic brain injury. We aimed to assess implementation and effectiveness of the Pediatric Guideline Adherence and Outcomes (PEGASUS) programme in children with severe traumatic brain injury.We did a prospective hybrid implementation and effectiveness study at the Harborview Medical Center (Seattle, WA, USA). We included children (aged18 years) with traumatic brain injury (trauma mechanism and image findings). We assessed service provision, adherence to three key performance indicators, and discharge outcomes associated with the PEGASUS programme. The three key performance indicators were early initiation of enteral (oral or tube feeds) or parenteral nutrition; avoidance of any unwanted hypocarbia (PaCOBetween May 1, 2011, and July 1, 2017, 199 children (median age 11·9 years [IQR 3·4-16·1]) participated in the PEGASUS programme, of whom 193 (97%) had severe traumatic brain injury and six (3%) had moderate traumatic brain injury. 105 patients contributed data for all three key performance indicators. Adherence to at least one key performance indicator was achieved by 101 (96%) of 105 participants, and 44 (42%) achieved adherence to all three key performance indicators. Programme participants achieved adherence to the key performance indicators of hypocarbia (76 of 105 [72%]), nutrition (162 of 199 [81%]), and cerebral perfusion pressure (128 of 199 [64%]). Adherence to the nutrition key performance indicator was associated with higher discharge survival (relative risk [RR] 2·70, 95% CI 1·54-4·73) and a more favourable discharge disposition (3·05, 1·52-6·11). Adherence to the cerebral perfusion pressure key performance indicator was also associated with higher discharge survival (RR 1·33, 95% CI 1·12-1·59) and favourable disposition (1·53, 1·19-1·96). Adherence to each additional key performance indicator was associated with higher survival (RR 1·27, 1·12-1·44) and a more favourable discharge disposition (1·46, 1·23-1·72), in a dose-response manner.The multilevel, hospital-wide, high-fidelity PEGASUS programme might benefit children and adolescents admitted to the emergency department with severe traumatic brain injury. Cerebral perfusion pressure, nutrition, and hypocarbia targets are essential components of the PEGASUS programme and are associated with favourable discharge outcomes.National Institutes of Health.

Objectives To determine how income-based disparities in a yearly dental visit (the Healthy People 2020 Leading Health Indicator for Oral Health) changed since legislation to expand dental coverage and to compare disparity trends in children and adults. Methods We analyzed Medical Expenditure Panel Survey (MEPS) 1997-2016 to determine yearly dental visit rates for US children and adults by family income. We determined measures of income disparity, including the Slope Index of Inequality (SII) and the Relative Index of Inequality (RII) and examined trends in yearly dental visit, SII, and RII using joinpoint regression. Results Income-based disparities, absolute and relative, narrowed over time for children. Steady upwards trends in yearly dental visit rates were observed for poor and low-income/poor children and no joinpoint was identified that corresponded to legislation expanding dental care coverage for lower income children. Relative income-based disparities in yearly dental visit rates widened for adults over 20 years. After declining for 14 years, yearly dental visit rate increased for poor adults from 2013 to 2016 suggesting a possible positive effect in adult dental care use trends following enactment of the Affordable Care Act. Conclusion In 1997, US children and adults had similar levels of income-based disparity in yearly dental visits, but by 2016, they differed markedly. Trends in income- based disparities in yearly dental visit rate narrowed for children but widened for adults. There are lessons from the expansion of dental care coverage for children that could be applied to improve access to dental care for adults.

For many teenagers, obtaining a driver’s license is a rite of passage, conferring the ability to independently travel to school, work, or social events. However, immaturity, inexperience, and risky behavior put newly licensed teen drivers at risk. Motor vehicle crashes are the most common cause of mortality and injury for adolescents and young adults in developed countries. Teen drivers (15–19 years of age) have the highest rate of motor vehicle crashes among all age groups in the United States and contribute disproportionately to traffic fatalities. In addition to the deaths of teen drivers, more than half of 8- to 17-year-old children who die in car crashes are killed as passengers of drivers younger than 20 years of age. This policy statement, in which we update the previous 2006 iteration of this policy statement, is used to reflect new research on the risks faced by teen drivers and offer advice for pediatricians counseling teen drivers and their families.

Introduction The prognosis for most patients with esophageal adenocarcinoma (EAC) is poor because they present with advanced disease. Models developed to identify patients at risk for EAC and increase early detection have been developed based on data from case–control studies. We analysed data from a prospective study to identify factors available to clinicians that identify individuals with a high absolute risk of EAC. Methods We collected data from 3 55 034 individuals (all older than 50 years) without a prior history of cancer enrolled in the UK Biobank prospective cohort study from 2006 through 2010; clinical data were collected through September 2014. We identified demographic, lifestyle, and medical factors, measured at baseline, that associated with development of EAC within 5 years using logistic regression analysis. We used these data to create a model to identify individuals at risk for EAC. Model performance was assessed using area under the receiver operating characteristics curve (AUROC), sensitivity, and specificity analyses. Results Within up to 5 years of follow up, 220 individuals developed EAC. Age, sex, smoking, body mass index, and history of esophageal conditions or treatments identified individuals who developed EAC (AUROC, 0.80; 95% CI, 0.77–0.82). We used these factors to develop a scoring system and identified a point cut off that 1 04 723 individuals (29.5%), including 170 of the 220 cases with EAC, were above. The scoring system identified individuals who developed EAC with 77.4% sensitivity and 70.5% specificity. The 5 year risk of EAC was 0.16% for individuals with scores above the threshold and 0.02% for individuals with scores below the threshold. Conclusions We combined data on several well-established risk factors that are available to clinicians to develop a system to identify individuals with a higher absolute risk of EAC within 5 years. Studies are needed to evaluate the utility of these factors in a multi-stage, triaged, screening program.

This issue marks the end of my 10-year term as editor-in-chief of Injury Prevention . Rod McClure, the incoming editor, will assume his responsibilities with the next volume. I am extraordinarily pleased with his selection and look forward to seeing the evolution of the journal under his competent stewardship. As the transition approaches, I would like to offer a few thoughts and ideas from my time with the journal and the privileged position it has given me to observe our field and the many academics and practitioners who work therein. I believe we have made progress over the last decade. It’s an exciting time to work in injury control. New opportunities and new issues arise daily. And while I don’t presume to know what is best for the field, there are some overarching themes that I think bear recognition. We are getting bett er at gathering data for prevention. The Global Burden of Disease estimates are remarkable in their scope and inclusiveness1; they should drive policy and priority setting. But to do so, they must be updated continuously, their models tested and refined against available data, and their limits recognised. If there are gaps in the raw data needed to generate meaningful regional, national, or subnational estimates, we must identify these and call for their collection. One-off well-conducted community surveys are likely to be more useful in these …

Possible external reservoirs for extraintestinal pathogenic Escherichia coli (ExPEC) strains that cause infections in humans are poorly defined. Because of the tremendous human health importance of ExPEC infections, we assessed surface waters and domesticated and wild animals in Minnesota and Wisconsin as potential reservoirs of ExPEC of human health relevance. We characterized 595 E. coli isolates (obtained from 1999 to 2002; 280 from seven surface water sites, 315 from feces of 13 wild and domesticated animal species) for phylogroup and virulence genotype, including inferred ExPEC status, by using multiplex PCR-based methods. We also compared the pulsed-field gel electrophoresis (PFGE) profiles of the isolates with a large private PFGE profile library. We found a predominance of non-ExPEC strains (95% and 93% among water and animal isolates, respectively), which were mainly from phylogroups A and B1, plus a minority of ExPEC strains (5% and 7% among water isolates and animal isolates, respectively), predominantly from phylogroup B2. The ExPEC strains, although significantly associated with cats, dogs, and turkeys, occurred in several additional animal species (goat, horse, chicken, pig) and were distributed broadly across all surface water sites. Virulence gene content among the animal source ExPEC isolates segregated significantly in relation to host species, following established patterns. PFGE analysis indicated that 11 study isolates closely matched (94% to 100% profile similarity) reference human clinical and fecal isolates. These findings imply what probably is a low but non-zero risk to humans from environmental and animal source E. coli isolates, especially those from specific human-associated animal species. IMPORTANCE Our detection of potentially pathogenic strains that may pose a health threat to humans among E. coli isolates from surface waters and wild and domesticated animals suggests a need for heightened attention to these reservoirs as possible sources for human acquisition of disease-causing E. coli . Although cats, dogs, and turkeys were especially high-prevalence sources, the presence of such strains in other animal species and at all sampled water sites suggests that this potential risk may be widespread.

Background & Aims: Human papillomavirus (HPV), which may reach the esophagus via orogenital transmission, has been postulated to be associated with esophageal adenocarcinoma. A systematic review of the literature investigating the prevalence of infectious agents in esophageal adenocarcinoma and Barrett's esophagus was undertaken.Methods: Using terms for viruses and esophageal adenocarcinoma, the Medline, Embase and Web of Science databases were systematically searched for studies published, in any language, until June 2016 that assessed the prevalence of viral agents in esophageal adenocarcinoma or Barrett’s esophagus. Random effects meta-analyses of proportions were used to calculate the pooled prevalence and 95% confidence intervals (CI) of infections in esophageal adenocarcinoma and Barrett's esophagus.Results: A total of 30 studies were included. The pooled prevalence of HPV in esophageal adenocarcinoma tumour samples was 13% (n=19 studies, 95% CI: 2-29%) and 26% (n=6 studies, 95% CI: 3-59%) in Barrett’s esophagus samples. HPV prevalence was higher in esophageal adenocarcinoma tissue than in esophageal tissue from healthy controls (n=5 studies, pooled odds ratio=3.31, 95% CI: 1.15-9.50). The prevalence of Epstein-Barr virus (EBV) in esophageal adenocarcinoma was 6% (n=5, 95% CI: 0-27%). Few studies have assessed other infectious agents. For each of the analyses, considerable between-study variation was observed (I2=84-96%), however sensitivity analyses did not reveal any major sources of heterogeneity.Conclusions: The prevalence of HPV and EBV in esophageal adenocarcinoma is low compared to other viral associated cancers but may have been hampered by small sample sizes and detection methods susceptible to fixation processes. Additional research with adequate sample size and high quality detection methods is required.

Objective To evaluate the relationship between bus stop characteristics and pedestrian–motor vehicle collisions. Methods This was a matched case–control study where the units of study were pedestrian crossings in Lima, Peru. We performed a random sample of 11 police commissaries in Lima, Peru. Data collection occurred from February 2011 to September 2011. A total of 97 intersection cases representing 1134 collisions and 40 mid-block cases representing 469 collisions that occurred between October 2010 and January 2011, and their matched controls, were included. The main exposures assessed were presence of a bus stop and specific bus stop characteristics. The main outcome measure was occurrence of a pedestrian–motor vehicle collision. Results Intersections with bus stops were three times more likely to have a pedestrian–vehicle collision (OR 3.28, 95% CI 1.53 to 7.03), relative to intersections without bus stops. Formal and informal bus stops were associated with higher odds of a collision at intersections (OR 6.23, 95% CI 1.76 to 22.0 and OR 2.98, 1.37 to 6.49). At mid-block sites, bus stops on a bus-dedicated transit lane were also associated with collision risk (OR 2.36, 95% CI 1.02 to 5.42). All bus stops were located prior to the intersection, contrary to practices in most high-income countries. Conclusions In urban Lima, the presence of a bus stop was associated with a threefold increase in risk of a pedestrian collision. The highly competitive environment among bus companies may provide an economic incentive for risky practices, such as dropping off passengers in the middle of traffic and jockeying for position with other buses. Bus stop placement should be considered to improve pedestrian safety.

Nonfatal injury is common among adolescents in the U.S., but little is known about the bi-directional associations between injury and mental health. Utilizing a nationally representative sample of U.S. adolescents, we examined 1) associations between lifetime mental health history and subsequent injury; 2) concurrent associations between injury and mental health; and 3) associations between injury and subsequent mental disorders. Data were drawn from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A), a national survey of adolescents aged 13 through 17 years (N = 10,123). Twelve-month prevalence of nonfatal injury requiring medical attention was assessed along with lifetime, 12-month, and 30-day prevalence of DSM-IV depressive, anxiety, behavior, substance use, and bipolar disorders. We used Poisson regression to examine associations between 1) lifetime history of mental disorders and 12-month exposure to injury; 2) concurrent associations between 12-month exposure to injury and 12-month prevalence of mental disorders; and 3) 12-month exposure to injury and 30-day prevalence of mental disorders. A total of 11.6% of adolescents experienced an injury requiring medical attention in the year before the survey. Lifetime history of mental disorders was not associated with past-year injury. Behavior and bipolar disorders were concurrently associated with past-year injury. Past-year injury occurrence predicted increased risk for past-month anxiety disorders and decreased risk of past-month depressive disorders. Our findings reveal reciprocal associations between injury and mental disorders and highlight the need for systematic assessment, prevention, and treatment of mental disorders among injured youth.

Severe traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. In 2003 and 2012, the Brain Trauma Foundation established and refined evidence-based guidelines for management of severe TBI in children. A recent multicenter study demonstrated an association between TBI guideline adherence and improved discharge survival. However, this study also showed large variation in adherence to pediatric TBI management at our level 1 pediatric trauma center, where overall adherence to fourteen pediatric intensive care unit (PICU) TBI clinical indicators was 64%. The aim of this quality improvement project was to increase TBI guideline adherence by implementing a standard care pathway for PICU management of children with severe TBI. A multi-disciplinary approach was utilized to develop the Pediatric Guideline Adherence and Outcomes (PEGASUS) care pathway, and iterative PDCA cycles were performed. Over an 18 month period following pathway implementation, overall PICU clinical guideline adherence rate increased to 80%.

Background Unintentional falls from windows are an important cause of paediatric morbidity. There have been no controlled studies to identify modifiable environmental risk factors for window falls in young children. The authors have piloted a case–control study to test procedures for case identification, subject enrolment, and environmental data collection. Methods Case windows were identified when a child 0–9 years old presented for care after a fall from that window. Control windows were identified (1) from the child9s home and (2) from the home of an age- and gender-matched child seeking care for an injury diagnosis not related to a window fall. Study staff visited enrolled homes to collect window measurements and conduct window screen performance tests. Results The authors enrolled and collected data on 18 case windows, 18 in-home controls, and 14 matched community controls. Six potential community controls were contacted for every one enrolled. Families who completed the home visit viewed study procedures positively. Case windows were more likely than community controls to be horizontal sliders (100% vs 50%), to have deeper sills (6.28 vs 4.31 inches), to be higher above the exterior surface (183 vs 82 inches), and to have screens that failed below a threshold derived from the static pressure of a 3-year-old leaning against the mesh (60.0% vs 16.7%). Case windows varied very little from in-home controls. Discussion Case–control methodology can be used to study risk factors for paediatric falls from windows. Recruitment of community controls is challenging but essential, because in-home controls tend to be over-matched on important variables. A home visit allows direct measurement of window type, height, sill depth, and screen performance. These variables should all be investigated in subsequent, larger studies covering major housing markets.

Objective To increase the number and quality of injury prevention recommendations made by Washington State (USA) child death review teams. Design Before and after study design involving four intervention teams and 21 comparison teams. Methods Intervention teams received injury prevention training, collaborative process improvement coaching, and access to web based prevention resources. An equal number of randomly selected child death review case reports filed with the state before the intervention by the intervention and comparison teams were included in the baseline sample. All reports submitted by the intervention and comparison teams after the intervention were included in the follow-up sample. Reports were scored on the completeness of prevention related data elements and on the quality of written prevention recommendations. Results Data completion for prevention relevant items increased in intervention teams from 73% at baseline to 88% at follow-up. In comparison teams, this measure fell from 77% to 56% over the same period. The quality of written recommendations produced by intervention teams increased from 4.3 (95% CI 3.4 to 5.1) to 7.6 (95% CI 6.7 to 8.5), while comparison teams showed no significant change (4.0 (95% CI 2.5 to 5.3) to 3.7 (95% CI 2.2 to 5.2)). Specifically, improvements were noted in the identification of evidence based best practices and the development of clear, actionable written recommendations. Conclusion Injury prevention recommendations are generated in the systematic local review of child deaths. This process can be analysed, measured, supported, and improved.

Background Escherichia coli sequence type ST131 (O25:H4), associated with the CTX-M-15 extended-spectrum beta-lactamase, has emerged internationally as a multidrug-resistant pathogen but has received little attention in the United States. Methods From the SENTRY and Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) surveillance programs, 127 E. coli clinical isolates from hospitalized patients across the United States in 2007, stratified by extended-spectrum cephalosporin and fluoroquinolone phenotype and bla(CTX-M-15) genotype, were assessed for phylogenetic group, ST131 status, susceptibility profile, virulence genotype, gyrA and parC sequence, and pulsed-field gel electrophoresis profile. Results The 54 identified ST131 isolates (all fluoroquinolone resistant) accounted for an estimated 17% of the source populations, including 67%-69% of isolates resistant to extended-spectrum cephalosporins or fluoroquinolones, 55% of those resistant to both fluoroquinolones and trimethoprim-sulfamethoxazole, and 52% of multidrug-resistant isolates. Their distinctive virulence profiles were more extensive compared with other antimicrobial-resistant isolates but similarly extensive compared with antimicrobial-susceptible isolates. Pulsed-field profiling suggested ongoing dissemination among locales, with concentration of bla(CTX-M-15) within specific ST131 lineages. A historical ST131 isolate lacked the 2007 ST131 isolates' conserved fluoroquinolone resistance-associated single-nucleotide polymorphisms in gyrA and parC. Conclusions A single E. coli clonal group, ST131, probably caused the most significantly antimicrobial-resistant E. coli infections in the United States in 2007, thereby constituting an important new public health threat. Enhanced virulence and/or antimicrobial resistance compared with other E. coli, plus ongoing dissemination among locales, may underlie ST131's success. Urgent investigation of the sources and transmission pathways of ST131 is needed to inform mitigation efforts.

The Global Burden of Disease and Injury project (GBD) is a monumental undertaking. First commissioned by the World Bank in 1990, and more recently supported by the Bill and Melinda Gates Foundation, this study aims to quantify the global burden and distribution of mortality, morbidity and disability attributable to a comprehensive set of diseases, conditions and risk factors. Results are most commonly presented as disability adjusted life years (DALYs), a common metric that accounts for years of life lost and for years of life lived with pain, impairment or other disability. Causes are grouped into three large domains: (1) communicable, neonatal, maternal and nutritional disorders; (2) non-communicable diseases and (3) injuries. The methods employed to generate these estimates are both state-of-the-art and daunting, involving huge human and computational resources.1 The raw data are amassed from vital registries, community and household surveys, hospital discharge abstracts and a host of other sources, including published epidemiological studies. These data are fed into sophisticated modelling programmes that generate global, regional, national and—in some cases—subnational—estimates, along with appropriate uncertainty intervals. In some cases this means extrapolating assumptions from one country or region to another. In others, it means glossing over the important—but unmeasured—differences that occur within countries and among demographic subpopulations. These methods have been presented by the authors in multiple venues over the years and, while not without controversy, are generally seen as the best available …

OBJECTIVE. Preventive dental care is a cornerstone of optimal oral health. However, in 1996, only 38% of US children received preventive dental care. We used the National Survey of Children's Health to (1) describe the proportion of US children with ≥1 preventive dental visit within the previous year, (2) identify factors that were associated with preventive dental care use, and (3) test the hypothesis that preventive dental care use by near-poor children is associated with State Child Health Insurance Program policies for covering dental care. METHODS. The National Survey of Children's Health includes data from 102353 children, weighted to represent 72.7 million children, nationally. Our outcome of interest was ≥1 preventive dental visit in the past year. We conducted multivariate regression analysis to identify factors that were associated significantly with this outcome using Stata survey capabilities. RESULTS. In 2003, 72% of US children had a reported preventive dental care visit in the previous year. On multivariable analysis, we found that being young, black or multiracial relative to white, lower income, and lacking a personal doctor were variables with a significantly lower likelihood of a preventive dental visit. Children in states with State Child Health Insurance Program dental coverage and broadest income eligibility had a 24% higher likelihood of a preventive dental visit when compared with children in states with limited or no State Child Health Insurance Program coverage for dental services, on adjusted analysis. CONCLUSIONS. Although the proportion of US children with a preventive dental visit now is higher than previously reported, children who are at highest risk for dental problems still are those who are least likely to receive preventive dental care. When states cover preventive dental care at income eligibility levels ≥200% of the federal poverty level, there is a greater likelihood that near-poor children will receive preventive dental care.

1. Julia M. Bledsoe, MD* 2. Brian D. Johnston, MD, MPH† 1. *Division of General Pediatrics and Director, Center for Adoption Medicine 2. †Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle, WA After completing this article, readers should be able to: 1. Describe the changes in the demographic, medical, and developmental characteristics of internationally adopted children. 2. Discuss the role of the pediatrician in assessing information made available to families prior to adoption of a child abroad. 3. List conditions commonly seen in children adopted internationally and characterize their medical, developmental, and social consequences. 4. Describe the current understanding of the long-term medical, developmental, and emotional outcomes of international adoption. International adoption is an increasingly common phenomenon. With nearly 20,000 foreign-born adoptees entering United States families every year, most pediatricians can expect to encounter one or more of these children in their practices. However, as the demographics and medical risks of intercountry adoption continue to change, it also is likely that prospective adoptive parents will seek pediatric advice prior to completing their adoption. The goal of this review is to highlight the general and specific concerns that pediatric clinicians should address as they prepare families for international adoption. In 1989, approximately 8,000 children were adopted into United States homes from foreign countries. Most came from Korea, relinquished by young mothers who were stigmatized by out-of-wedlock pregnancy (Figure⇓). Most of these children received United States-style pediatric care and were nurtured in well-funded foster homes until their adoption was completed, usually during infancy. Figure. Immigrant visas issued to orphans coming to the United States by country of origin, 1989 versus 2002. Source: United States Department of State. By 2002, the number of intercountry adoptions had more than doubled, with most children coming from either Russia or China (Figure⇑). This shift in country of origin was accompanied by a change in the general health and well-being of international adoptees. For example, among children available for adoption from Russia, as many as 30% were born preterm or were of …

Background In two other papers in this issue, the rationale, development, implementation, experimental design, approach to evaluation, and early results of a program to deliver developmental and behavioral services to all infants in primary care practice were described. Positive effects were seen for parental satisfaction, including decreased disenrollment, provider satisfaction, parenting practices, and health outcomes. Methods In the present article, the results are reviewed and implications of our findings for the delivery of care, families, healthcare systems, and further research are discussed. Results Findings that have broad implications are as follows: (1) developmental and behavioral services can be delivered successfully in practice using dedicated professionals to deliver and integrate services; (2) the “planned care model” was useful in program implementation for making “the right thing to do, the easy thing to do”; (3) the added focus on satisfaction and cost helps to develop the “business case” for broad scale implementation; (4) bonding of parents to organizations has marketing implications; (5) the program provides positive effects for all parents, not just high-risk parents; and (6) several research questions emerge, including persistence of effects on health outcomes, costs, and utilization. Conclusions The authors conclude that study results have implications for preventive services, families, child healthcare in office practice, healthcare systems, and healthcare policy. In this ongoing study, examination of intervention effects at 30 months of age shoud be informative. Further research is warranted as it remains to be seen whether or not these interventions can become viable ongoing programs.

Background Healthy Steps (HS) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents. This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called "PrePare" (PP). Methods The design was a quasi-experimental comparison of intervention families with families receiving usual care. Within the intervention, families were assigned randomly to begin receiving Healthy Steps services prenatally (PP+HS) or shortly after birth (HS). We used a systems model, PRECEDE/PROCEED, for planning, implementation, and process evaluation. Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting, parenting behaviors, and satisfaction and loyalty to the health plan. Results The sample of 439 families was distributed as follows: usual care ( n =136), prenatal initiation of services (PP+HS; n =151), and postnatal Healthy Steps (HS; n =152). Information about program implementation, including provider satisfaction, is provided for the early phases of the study (through age 3 months). The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers, most of whom considered the program valuable to their patients. Relative to families in the comparison group, families in the intervention group received more usual care services and more intervention-specific services. Conclusions The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system. The program was considered valuable for parents by providers and parents. Participating families received more services and a greater variety of services than families in usual care. Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers.

This paper reports the process outcomes of a randomized trial of a one-session Motivational Interviewing (MI) intervention conducted with youth (12–20 years) in a hospital emergency department (ED) while undergoing medical care for an injury. The interventions targeted six behaviors placing youths at high risk for injury. Those youth whose counselors perceived their readiness to increase between the start and end of the MI session were 4.5 times more likely to have improved their use of seat belts 6 months later compared with youth who were not perceived to have increased in readiness during the session.

We analyze records of all emergency department (ED) patients with extremity or clavicular fractures to describe analgesic use, compare analgesia between adults and children, and compare analgesia between the subset of these adults and children with documented moderate or severe pain. Among children, we compare treatment between pediatric and nonpediatric facilities.Analysis of the ED component of the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1997 through 2000 was conducted. The proportion of patients with closed extremity and clavicular fracture that received any analgesic and narcotic analgesic medications was determined for each age category. Survey-adjusted regression analyses compared pain and narcotic medications by age and ED type (pediatric versus other). Analyses were repeated for the subset of patients with moderate or severe pain severity scores.Of 2,828 patients with isolated closed fractures of the extremities or clavicle, 64% received any analgesic and 42% received a narcotic analgesic. Pain severity scores were recorded for 59% of visits overall, 47% of children younger than 4 years, and 34% of children younger than 1 year. Among patients with documented moderate or severe pain, 73% received an analgesic and 54% received a narcotic analgesic. Compared with adults, a lower proportion of children (or = 15 years) received either any analgesic or a narcotic analgesic (P.001). After adjustment for confounders and survey design, the proportion of patients aged 0 to 3, 4 to 8, 9 to 15, 16 to 29, 30 to 69, and 70 years and older who received any analgesic was 54% (95% confidence interval [CI] 41% to 67%), 63% (95% CI 57% to 68%), 60% (95% CI 57% to 64%), 67% (95% CI 62% to 73%), 68% (95% CI 64% to 72%), and 58% (95% CI 52% to 65%), respectively; the proportion who received a narcotic analgesic was 21% (95% CI 11% to 31%), 30% (95% CI 22% to 37%), 27% (95% CI 23% to 32%), 47% (95% CI 40% to 54%), 51% (95% CI 46% to 56%), and 41% (95% CI 35% to 48%), respectively. Compared with children treated in other EDs, children treated in pediatric EDs were about as likely to receive any analgesia (adjusted relative risk [RR] 1.1; 95% CI 0.9 to 1.3) or narcotic analgesia (adjusted RR 0.9; 95% CI 0.6 to 1.2).In pediatric and adult patients, pain medications were frequently not part of ED treatment for fractures, even for visits with documented moderate or severe pain. Pain severity scores were often not recorded. Pediatric patients were least likely to receive analgesics, especially narcotics.

Study objective: Using nationally representative data, we sought to describe the incidence of emergency department (ED) visits for dental-related complaints for children and adults in the United States. We hypothesized that dental-related ED visits were more likely than other ED visits to have Medicaid or no insurance as the payer. Methods: We used data from the 1997 to 2000 National Hospital Ambulatory Medical Care Survey, a national probability sample survey of hospital ED visits that is conducted by the National Center for Health Statistics. From these data, all ED visits in which one of the reasons for the visit was toothache or tooth injury were compiled and used to determine national estimates of counts and rates of ED visits for dental-related complaints. Logistic regression analysis on the outcome variable, presentation to the ED with a dental complaint (versus other problem), was performed to determine the association with payer and other covariates. Results: During the 4-year period from 1997 to 2000, there were an estimated 2.95 million ED visits in the United States for complaints of tooth pain or tooth injury, for an average of 738,000 visits annually. Population-based rates and proportion of all ED visits for dental complaints were highest in the 19- to 35-year-old group, accounting for 1.3% of all ED visits and 5.6 ED visits per 1,000 people in this age category. "Dental problem, not otherwise specified" was the most commonly assigned International Classification of Diseases, Ninth Revision , Clinical Modification diagnosis. Multivariate logistic regression results indicated that the adjusted odds of presentation to the ED for a dental complaint compared with other problems were significantly elevated for visits in which Medicaid or self-pay was listed as the payer relative to those with private insurance. Conclusion: EDs are an important point of care for dental-related complaints, particularly for individuals who lack private insurance. ED providers should be equipped to triage, diagnose, provide basic treatment, and ensure appropriate follow-up care for dental problems, which may require enhancement of dental training for emergency medicine providers and improved dental care during and after ED visits. [ Ann Emerg Med. 2003;42:93-99.]

It is with great pleasure that I call your attention to a milestone in our journal's history. This issue marks the first of our 21st volume, meaning that Injury Prevention is now 20 years old! The journal will be celebrating a number of ways. Those reading the print edition will already have noted the new cover design. We offered our readers an opportunity to vote, via social media, on one of three designs, and what you see here was the clear favourite. It is vexingly difficult to come up with an abstract representation of injury prevention. This design, at least, suggests caring hands and the lifespan focus of the journal. We are also reprinting a ‘classic’ paper from the journal in each issue this year. These classics were nominated by readers and selected by our editorial board as papers with a lasting impact in the field. Some represent ground-breaking science or innovative methodologies. Others ask provocative, novel questions or propose models useful in planning or pedagogy. All have been influential in ways …

August is high summer here in Seattle and the days are typically glorious. Visitors who have succumbed to the misperception that our skies are chronically grey and wet are astonished at the natural beauty of this region when the sun appears. Green forests frame our waterways with snowcapped mountains in the background. Unsurprisingly, absolutely everybody heads out doors to enjoy it while we can. The sad corollary of this activity on and around the water is a predictable increase in the number of drowning cases each summer. In high-income countries drowning is typically associated with occupational or recreational exposure. In our state, that recreation tends to happen on open water, while people enjoy boating on our rivers, lakes and coastal waters.1 Drowning prevention in these contexts requires a specific set of behaviours and interventions, often quite distinct from the strategies employed to combat drowning in low or middle income countries, in swimming pools or in bathing facilities. A trio of papers in this issue, along with a forthcoming study in press, …

Objective: Pedestrians comprise 78% of the road fatalities in Peru. The objective of this study was to explore the relationship between the walking environment and pedestrian–motor vehicle collisions. Methods: A matched case-control study was used to detect the odds of a pedestrian–motor vehicle collision at a pedestrian crossing location. Data were collected from 11 sampled police commissaries in Lima, Peru. Results: In a multivariable model adjusting for vehicle and pedestrian flow, pedestrian collisions were less likely in the presence of a curb and sidewalk on both roadway sides (odds ratio [OR] = 0.19, 95% confidence interval [CI], 0.11–0.33) or a pedestrian barricade (OR = 0.11, 95% CI, 0.01–0.81). There was a greater risk of collisions for each street vendor present (OR = 2.82, 95% CI, 1.59–5.00) or whether any parked vehicles (OR = 3.67, 95% CI, 1.18–11.4) were present. Conclusions: Improving or addressing these potentially modifiable features of the walking environment could improve pedestrian safety in Lima and in similar urban settings in low- and middle-income countries.

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

A fluoroquinolone-resistant Escherichia coli strain of sequence type ST131 caused severe septic arthritis and contiguous osteomyelitis in an 8-month-old girl, and colonized the girl's healthy mother, who shared a different fecal E. coli strain with the father. Within-household transmission can contribute to the dissemination of the emerging, multidrug-resistant ST131 clonal group, which has evident invasive potential for otherwise-healthy children.

Objective—To evaluate the feasibility, acceptability, and eVectiveness of an injury prevention program delivered by school based home visitors to the families of low income children attending preschool enrichment programs in Washington State. Study sample—The families of children attending preschool Head Start programs in two regions were eligible. A total of 213 families (77.8% of those eligible) from intervention sites, and 149 families (71.9% of those eligible) from concurrent comparison sites, agreed to participate and completed the trial. Intervention—Trained school personnel conducted home safety inspections as part of a planned home visit. Intervention families were oVered educational materials as well as smoke detectors, batteries, ipecac, and age appropriate car safety restraints based on results of the home inspection. Evaluation methods—At a repeat home visit three months later, the proportion of families with a positive change in injury prevention knowledge or behavior among those in the intervention group was compared with the proportion in the comparison group. Smoke detector presence and function were observed. Results—Among families without a working smoke detector at baseline, the intervention was associated with an increased probability of having a working detector at follow up (relative risk (RR) 3.3, 95% confidence interval (CI) 1.3 to 8.6). Intervention families were also more likely to report the presence of ipecac in the home (RR 4.7, 95% CI 3.0 to 7.3) at follow up and to have obtained an age appropriate booster seat (RR 4.1, 95% CI 1.9 to 8.8). The program was acceptable to client families and to the home visitors who conducted the intervention. Conclusions—Among the families of low income children enrolled in preschool enrichment programs, home safety inspections and the distribution of safety supplies by school based home visitors appears to improve knowledge and behavior related to poisoning, smoke detector installation, and car safety seat use over three months of follow up. (Injury Prevention 2000;6:305‐309)

Objective.To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling.Design.Retrospective cohort.Setting.King County, Washington.Participants.A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years).Outcome Measures.The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use.Results.There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56–1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk: .57; 95% confidence interval: .07–2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 2½ months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children.Conclusions.Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.

Multiple characteristics of pretherapy Escherichia coli urine isolates from 39 children with acute, uncomplicated cystitis (including specific virulence genes and phylogenetic groups) identified an increased risk for recurrent bacteriuria after 3-day (but not 10-day) therapy with amoxicillin-clavulanate. Rapid testing conceivably could facilitate rational selection of treatment duration for pediatric cystitis. Certain traits might represent good targets for preventive interventions.

Research is by definition an attempt to systematically investigate an issue so as to add to our understanding. It is a structured expression of our curiosity. Three papers in this issue sit at the limits of our search for knowledge—what we should know, what we can know and—maybe—how to know a little bit more. Colleges, understandably, are curious about the students they plan to enrol. I wasn't aware, however, that over 50% of colleges in the USA specifically ask prospective students about their criminal background.1 As Runyan and colleagues have noted, this is driven in part by the belief that a substantial proportion of crime on college campuses is perpetrated by students themselves. If one could predict which students are likely to be perpetrators, this could influence admission decisions or trigger some form of oversight, supervision or remediation. The authors report a strong positive association between precollege criminal activity and college misconduct.2 However, and to their great credit, the authors look beyond the epidemiologic association …

Safe walking environments are essential for protecting pedestrians and promoting physical activity. In Peru, pedestrians comprise of over three-quarters of road fatality victims. Pedestrian signalization plays an important role managing pedestrian and vehicle traffic and may help improve pedestrian safety. We examined the relationship between pedestrian-motor vehicle collisions and the presence of visible traffic signals, pedestrian signals, and signal timing to determine whether these countermeasures improved pedestrian safety. A matched case-control design was used where the units of study were crossing locations. We randomly sampled 97 control-matched collisions (weighted N=1134) at intersections occurring from October, 2010 to January, 2011 in Lima. Each case-control pair was matched on proximity, street classification, and number of lanes. Sites were visited between February, 2011 and September, 2011. Each analysis accounted for sampling weight and matching and was adjusted for vehicle and pedestrian traffic flow, crossing width, and mean vehicle speed. Collisions were more common where a phased pedestrian signal (green or red-lit signal) was present compared to no signalization (odds ratio [OR] 8.88, 95% Confidence Interval [CI] 1.32–59.6). A longer pedestrian-specific signal duration was associated with collision risk (OR 5.31, 95% CI 1.02–9.60 per 15-second interval). Collisions occurred more commonly in the presence of any signalization visible to pedestrians or pedestrian-specific signalization, though these associations were not statistically significant. Signalization efforts were not associated with lower risk for pedestrians; rather, they were associated with an increased risk of pedestrian-vehicle collisions.

A man found unresponsive after a physical altercation subsequently died after cardiopulmonary resuscitation efforts proved futile. Autopsy revealed only soft tissue injuries to the face without significant scalp bruising or craniocerebral trauma, insufficient to cause death. Toxicological analysis revealed high body fluid alcohol (ethanol) concentrations, blood: 88.4 mmol/L (407 mg/dL), urine: 114.6 mmol/L (528 mg/dL), and vitreous humour 97.0 mmol/L (447 mg/dL). Cause of death was attributed to the combination of high alcohol central nervous system depressant effects and concussive brain injury.

Injury is a major cause of morbidity and mortality among US children, and an important driver of health status globally. Despite its enormous burden, injury is preventable. Over the last 10 years, significant progress has been made in the reduction of unintentional injury among US children. However, aggregate trends mask important disparities by age group, region, and injury mechanism. Basic and translation research is needed to develop and test prevention strategies to address these new or recalcitrant problems. Motor vehicle occupant injury has fallen to historic lows, but challenges remain in protecting novice drivers and managing the distraction of new technologies. Injury to pedestrians has also declined, but likely as a result of decreased exposure as fewer children walk. This calls for a broader public health perspective to promote activity while enhancing safety. Deaths due to drowning are common and illustrate the difficulty in measuring and promoting appropriate supervision. Environmental modification and use of protective products may be a more appropriate response. Concussion in sport is another challenging issue: public health laws promote identification and appropriate management of concussed athletes, but less progress has been made on primary prevention of these injuries. Unintentional poisoning is on the rise, attributable to misuse of, and overdose with, prescription opioids. Injury deaths to infants are also increasing. This trend is driven in part by better death investigation that classifies more sleep-related deaths as suffocation events. Finally, we examine a sample of cross-cutting themes and controversies in injury control that might be amenable to empiric evaluation.

In early October of this year, over 1000 of our colleagues from 83 countries converged on Wellington, New Zealand, for Safety 2012, the 11th World Conference on Injury Prevention and Safety Promotion. Delegates were treated to warm hospitality, mild weather and an outstanding programme focused on ‘connecting pathways for a vibrant and safer future’. For me, the highlights included Dr Alan Lopez previewing the 2010 global burden of disease injury estimates, David Engwicht discussing uncertainty and intrigue as ‘mental speed bumps’ for traffic safety, and John Carnochan, a Scottish police officer, who vividly illustrated the intergenerational and community roots of youth violence. It is also always humbling to see what WHO Department of Violence and Injury Prevention and Disability (VIP), under the capable direction of Dr Etienne Krug, is able to achieve in the course of a biennium. Working …

It is not unusual for this journal to receive papers describing the epidemiology of an injury mechanism, and often endeavouring to identify risk factors associated with the outcome. In fact, we publish many such manuscripts.1–3 When discussing the motivation for a study or the implications of its results, authors will often state that risk factors they have identified could be used to ‘target’ injury control interventions towards individuals at particular injury risk. The rationale seems reasonable enough: find a demographic or behavioural marker that is associated with injury, and use this to direct limited or intensive prevention resources towards those at highest risk. But there are problems inherent in this approach that merit discussion. Of course, at some level, every program is targeted. Clinicians don't offer smoking cessation advice to non-smokers. Nor do we typically discuss child safety restraint with non-parenting adults. …

Death by unintentional poisoning is prevalent in the USA. A rare occurrence in the very young, unintentional poisoning is behind only road traffic injury and firearm violence as a cause of injury death among those 15–24 years old. It moves into second position for 25–34 year olds and is the leading cause of injury death from 35 to 54 years of age.1 Drug overdose death rates have risen steadily in the USA since 1970, nearly doubling in the last 10 years alone (figure 1). Figure 1 Age-adjusted unintentional poisoning mortality, USA 1999–2007. Data from Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). Available from http://www.cdc.gov/ncipc/wisqars. The US Centers for Disease Control attribute most of this increase to inappropriate use of prescription opioid medications.2 As clinicians have moved, rightly, towards more aggressive treatment of acute and chronic pain, prescription of narcotic painkillers has skyrocketed.3 While opioids are clearly useful for the treatment of acute pain, they are …

OBJECTIVES: The objective of this study was to identify child, parent, and family characteristics that are associated with short-term recurrence of injury within sibling groups. METHODS: A prospective cohort study was conducted of 92 children who were aged 0 to 15 years and treated for injury at a regional pediatric trauma center and their 166 siblings. The outcome of interest was a second or subsequent injury in the sibling group, occurring within 3 months of the index injury event. Explanatory variables included injury variables, child factors (age, gender, previous injury experience, behavior problems, and traumatic stress symptoms), parental factors (age, education, social support, depressive symptoms, and traumatic stress symptoms), and family factors (socioeconomic status, family function, family structure, and life events). Poisson regression was used in multivariable models with statistical adjustment for clustering within sibling groups. RESULTS: More than 19% of families had at least 1 child injured or reinjured during 3 months of follow-up. The rate of reinjury to index children (8.7%) was similar to that in siblings (7.2%). Controlling for age, gender, and race, the risk for reinjury during follow-up was increased with single-parent family structure (relative risk [RR]: 3.39 [95% confidence interval (CI): 1.69–6.80]), receipt of public assistance (RR: 3.65 [95% CI: 1.61–8.28]), and clinically significant posttraumatic stress disorder arousal symptoms in the child (RR: 3.76 [95% CI: 1.51–9.33]). CONCLUSIONS: Along with their siblings, children who receive treatment for injury are at short-term risk for additional injury. Children in single-parent households, in families who receive public assistance, and those with posttraumatic stress disorder arousal symptoms 1 month after injury to themselves or a sibling are at highest risk. These associations could be used to develop interventions to identify and support families through periods of high injury risk.

This summer, the New York Times ran a series of articles looking at the risks of distracted driving, especially as this relates to cell-phone use and text messaging while operating an automobile.1 The Times ran these pieces on their front page, generating considerable interest and spin-off coverage in other media. While acknowledging the difficulties of studying risk associated with a transient exposure, the stories emphasized that, in the USA, cell-phone use is the most prevalent driver distraction and one that is especially common among the youngest (and, at baseline, riskiest) drivers. Citing data from simulator studies, the author reported that cell phone use increased the risk of crashes or near crashes anywhere from four- to eightfold, an impact comparable with driving with a blood alcohol level above the legal limit.2 In a salacious aside, the series revealed that in 2003, researchers at the US National Highway Traffic Safety Administration compiled research demonstrating the risks of distracted driving but withheld these findings when the agency came under pressure from Congress.3 The Times also included data collected by researchers at the Virginia Tech Transportation Institute. In an elegant design, their studies use longitudinal data from event recorders mounted in vehicle fleets. These naturalistic studies are …

Background To evaluate the impact of a walking school bus (WSB) program on student transport in a low-income, urban neighborhood. Methods The design was a controlled, quasi-experimental trial with consecutive cross-sectional assessments. The setting was three urban, socioeconomically disadvantaged, public elementary schools (1 intervention vs. 2 controls) in Seattle, Washington, USA. Participants were ethnically diverse students in kindergarten-5th grade (aged 5–11 years). The intervention was a WSB program consisting of a part-time WSB coordinator and parent volunteers. Students' method of transportation to school was assessed by a classroom survey at baseline and one-year follow-up. The Pearson Chi-squared test compared students transported to school at the intervention versus control schools at each time point. Due to multiple testing, we calculated adjusted p-values using the Ryan-Holm stepdown Bonferroni procedure. McNemar's test was used to examine the change from baseline to 12-month follow-up for walking versus all other forms of school transport at the intervention or control schools. Results At baseline, the proportions of students (n = 653) walking to the intervention (20% +/- 2%) or control schools (15% +/- 2%) did not differ (p = 0.39). At 12-month follow up, higher proportions of students (n = 643, p = 0.001)) walked to the intervention (25% +/- 2%) versus the control schools (7% +/- 1%). No significant changes were noted in the proportion of students riding in a car or taking the school bus at baseline or 12-month follow up (all p > 0.05). Comparing baseline to 12-month follow up, the numbers of students who walked to the intervention school increased while the numbers of students who used the other forms of transport did not change (p < 0.0001). In contrast, the numbers of students who walked to the control schools decreased while the numbers of students who used the other forms of transport did not change (p < 0.0001). Conclusion A WSB program is a promising intervention among urban, low-income elementary school students that may promote favorable changes toward active transport to school. Trial Registration ClinicalTrials.gov NCT00402701

My career in education – moral and occupational – has been marked by dramatic changes and dramatic continuities in what it means to be educated. As a sociological life and as an intellectual journey my biography seems to consist of a set of ruptures and tensions and inconsistencies. These remain unresolved and are difficult to explain but form the backbone of the story I will tell here. Thinking back, the tensions that have made up my personal experience of education have perhaps made necessary a constant need to challenge and unsettle myself, to reconsider, move on, or perhaps move away – to be something else.

Epidemiological and phylogenetic associations of the pks genomic island of extraintestinal pathogenic Escherichia coli (ExPEC), which encodes the genotoxin colibactin, are incompletely defined. clbB and clbN (as markers for the 5′ and 3′ regions of the pks island, respectively), clbA and clbQ (as supplemental pks island markers), and 12 other putative ExPEC virulence genes were newly sought by PCR among 131 published E. coli isolates from hospitalized veterans (62 blood isolates and 69 fecal isolates). Blood and fecal isolates and clbB -positive and -negative isolates were compared for 66 newly and previously assessed traits. Among the 14 newly sought traits, clbB and clbN (colibactin polyketide synthesis system), hra (heat-resistant agglutinin), and vat (vacuolating toxin) were significantly associated with bacteremia. clbB and clbN identified a subset within phylogenetic group B2 with extremely high virulence scores and a high proportion of blood isolates. However, by multivariable analysis, other traits were more predictive of blood source than clbB and clbN were; indeed, among the newly sought traits, only pic significantly predicted bacteremia (negative association). By correspondence analysis, clbB and clbN were closely associated with group B2 and multiple B2-associated traits; by principal coordinate analysis, clbB and clbN partitioned the data set better than did blood versus fecal source. Thus, the pks island was significantly associated with bacteremia, multiple ExPEC-associated virulence genes, and group B2, and within group B2, it identified an especially high-virulence subset. This extends previous work regarding the pks island and supports investigation of the colibactin system as a potential therapeutic target.

OBJECTIVE Opinion is divided on the value of repeat head computed tomography for guiding clinical management of pediatric patients with blunt head trauma. This study describes the prevalence of worsening brain injury on repeat computed tomography, predictors of worsening computed tomography findings, and the frequency of neurosurgical intervention after the repeat computed tomography. DESIGN Retrospective cohort study. SETTING All patients were admitted to a level I pediatric trauma center between 1994 and 2003. PATIENTS Children

I was very disappointed, along with many of you, when Safety 2014: the World Conference on Injury Prevention and Safety Promotion , scheduled to convene in Atlanta last year, was cancelled. These biennial meetings have provided the single best opportunity for members of our disparate and eclectic global community to come together, learn from each other and maintain momentum in the worldwide struggle against violence and injury. The gathering allows us to share new research, see new approaches to implementation and to influence the current vision and direction of the field. Given the wide …