Doctor shopping before and after a visit to a paediatric emergency department

BACKGROUND

Use of multiple care providers is known to be associated with poor continuity of care.

OBJECTIVES

To estimate the prevalence of and identify risk factors for doctor shopping by parents of children with common acute illnesses seen in the emergency department (ED) of a children's hospital.

SETTING

ED at the Montreal Children's Hospital (MCH), Montreal, Quebec.

METHODS

Doctor shopping was defined as visiting three or more different care sites (the MCH ED, other EDs, outpatient clinics or private offices) for a single illness episode, including all visits occurring within successive 72 h periods up to a maximum of 15 days before and after an ED visit from April 1995 to March 1996. Logistic regression was used to compare characteristics of illness episodes with doctor shopping versus those without.

RESULTS

Of the total 40,150 visits during the study period, doctor shopping was observed in 18% of the visits. The risk of doctor shopping was positively associated with an initial visit at other EDs (odds ratio [OR] 9.08, 95% CI 7.16 to 11.52), outpatient clinics (OR 4.47, 95% CI 3.71 to 5.37) or private offices (OR 1.71, 95% CI 1.48 to 1.96) versus those who visited the MCH ED first. The risk did not differ according to whether a paediatrician versus a general practitioner saw the child during the initial visit (OR 0.99, 95% CI 0.86 to 1.15). Some diagnoses (the reference category was upper respiratory infection), including urinary tract infection (OR 3.31, 95% CI 2.58 to 4.23) and gastroenteritis (OR 1.59, 95% CI 1.35 to 1.88), were associated with an increased risk of doctor shopping, while asthma was associated with a reduced risk (OR 0.71, 95% CI 0.60 to 0.86).

CONCLUSION

Doctor shopping is common among parents of children with acute illnesses. Parents of children who were seen in the MCH ED first were less likely to doctor shop, perhaps because the parents were more confident about the advice and treatment received. Further research should investigate the underlying reasons for doctor shopping, eg, services other than an ED were not available and parents' perceptions of the quality of health services.

Prevalence of helmet use by users of bicycles, push scooters, inline skates and skateboards in Toronto and the surrounding area in the absence of comprehensive legislation: an observational study

BACKGROUND

Legislation in the province of Ontario, Canada, mandates users under the age of 18 to wear a helmet when they ride a bicycle, and legislation has been shown to significantly increase rates of bicycle helmet use. Legislation does not exist in Ontario for older bicyclists or for users of other non-motorised modes of transportation, and there are no current data available regarding rates of helmet use in these categories. This study was designed to determine the prevalence of helmet use among users of bicycles, skateboards, push scooters and inline skates in Toronto, Ontario, and the surrounding area. Further analysis was performed to examine factors associated with helmet use.

METHODS

We performed a cross-sectional, observational study. Three trained, stationary observers captured 6038 users of bicycles (5783), skateboards (77), inline skates (165) and push scooters (13) in the summer of 2009. Observations were separated into three time periods capturing commuters, midday users and recreational users. A general linear model was used to assess the factors associated with helmet use among bicyclists.

RESULTS

Helmets were worn by 48.9% of all users observed and 50.0% of all bicyclists. Among bicyclists, females were more likely to wear helmets than males (prevalence ratio 1.27, 95% CI 1.17 to 1.36), while children were significantly more likely to wear helmets than adults (prevalence ratio 1.17, 95% CI 1.37 to 2.15). Significant behavioural variation was observed among users during the three observation periods (p<0.001), with commuters being the most likely to wear a helmet.

CONCLUSION

In the absence of comprehensive legislation encompassing all ages of users, only half of users of non-motorised, wheeled transportation devices are choosing to wear a helmet to protect against traumatic brain injury. Implementation of evidence-based strategies to increase helmet use, such as the introduction of legislation encompassing all ages and all equipment, is required.

Capturing paediatric injury in Ontario: differences in injury incidence using self-reported survey and health service utilisation data

OBJECTIVE

Population-based health surveys are increasingly popular sources of data on injury occurrence. Self-reported surveys can yield estimates of the total incidence of non-fatal injuries while simultaneously capturing a rich repository of contextual data that may be informative for exploring determinants of injury risk. Although survey data are rarely recognised as complete, several researchers have expressed concerns about the sensitivity and validity of self-reported injury data, questioning whether captured cases are representative of the population experience of injury, particularly among children and youth. The present study sought to compare the population incidence of paediatric injury estimated from self-reported survey responses to those documented by a complete-capture health service utilisation database among Ontario children.

METHODS

Injury incidence rates documented from the National Longitudinal Survey of Children and Youth and the National Population Health Survey were compared with those reported in Canada's National Ambulatory Care Reporting System for Ontario youth aged 0-19 years for fiscal year 2002/3, stratified by the child's age and geographical location of residence.

RESULTS

The two self-reported health surveys underestimated the population incidence of injury among Ontario children by at least 49% and 53%, respectively. Systematic errors exist in survey data capture such that injuries in infants and preschoolers (<4 years of age) and urban residents were most likely to be missed by the population health surveys.

CONCLUSION

Injury incidence estimated through self-report is not representative of the population burden and experience of paediatric injury for Ontario children, and may produce biased estimates of risk when analysed as independent sources of data.

Developing injury indicators for Canadian children and youth: a modified-Delphi approach

OBJECTIVE

To develop a set of national injury indicators for Canadian children and youth which will eventually be used to reflect and monitor identified prevention priorities.

METHODS

The Canadian Injury Indicators Development Team brought together injury researchers, policy makers, and practitioners to develop injury indicators in the following areas: overall health services implications; motor vehicle occupant; sports, recreation, and leisure; violence; and trauma care, quality, and outcomes. A modified-Delphi process was used to establish a set of indicators that met evidence-based criteria, were useful, and that would prompt action. Each indicator was rated by 132 respondent injury experts and stakeholders on its usefulness and ability to prompt action to reduce injury among Canadian children and youth.

RESULTS

From an initial list of 51 indicators, a refined set of 34 indicators was established. Indicators were grouped into three categories related to: policies; risk and protective factors; and outcomes. Indicators related to motor vehicle injury were rated as most useful and most able to prompt action. Injury mortality rate and injury hospitalisation rate were also rated highly for both usefulness and ability to prompt action. Policy, violence, sport and recreation, and trauma indicators were all rated higher for usefulness, but somewhat lower for ability to prompt action.

CONCLUSION

Results suggest that a broad-based modified-Delphi process is an important first step in developing useful and relevant indicators for injury prevention activity focused on Canadian children and youth.

Safety standards and socioeconomic disparities in school playground injuries: a retrospective cohort study

Background

Playground injuries are fairly common and can require hospitalization and or surgery. Previous research has suggested that compliance with guidelines or standards can reduce the incidence of such injuries, and that poorer children are at increased risk of playground injuries.

Objective

The objective of this study was to determine the association between playground injury and school socioeconomic status before and after the upgrading of playground equipment to meet CSA guidelines.

Methods

Injury data were collected from January 1998-December 1999 and January 2004 - June 2007 for 374 elementary schools in Toronto, Canada. The objective of this study was to investigate the effect of a program of playground assessment, upgrading, and replacement on school injury rates and socio-economic status. Injury rates were calculated for all injuries, injuries that did not occur on equipment, and injuries on play equipment. Poisson regression was performed to determine the relationship between injury rates and school socio-economic status.

Results

Prior to upgrading the equipment there was a significant relationship between socio-economic status and equipment-related injuries with children at poorer schools being at increased risk (Relative risk: 1.52 [95% CI = 1.24-1.86]). After unsafe equipment was upgraded, the relationship between injury and SES decreased and was no longer significant (RR 1.13 [95% CI = 0.95-1.32]).

Conclusions

Improvements in playground equipment can result in an environment in which students from schools in poorer neighbourhoods are no longer at increased risk of injuries on play equipment.

Tai Chi workplace program for improving musculoskeletal fitness among female computer users

BACKGROUND

Workplace computer use has increased dramatically in recent years and has been linked to musculoskeletal disorders, a leading cause of work disability and productivity losses in industrialized nations. Tai Chi is a simple, convenient workplace intervention that may promote musculoskeletal health without special equipment or showering, yet no study has investigated Tai Chi as a workplace physical exercise for health promotion.

OBJECTIVE

To examine the effects of a workplace Tai Chi (TC) intervention on musculoskeletal fitness and psychological well-being among female university employees who are computer users.

METHODS

The exercise program consisted of two 50 minute TC classes per week for 12 consecutive weeks during the months of May-August 2007. Fifty-two participants were enrolled in a class conducted on campus by a professional TC practitioner during the lunch hour. Socio-demographic characteristics, including information on age, marital status, ethnicity, job category and perceived overall health were collected from all participants. Fitness testing conducted by qualified personnel was assessed pre- and post-program. The tests included resting heart rate, resting blood pressure, anthropometric measures, musculoskeletal fitness and back fitness. Psychological well-being was assessed by the Perceived Stress Scale pre- and post-program.

RESULTS

There were significant positive results in several areas including resting heart rate, waist circumference and hand grip strength. Results showed that the TC program was effective in improving musculoskeletal fitness and psychological well-being.

CONCLUSIONS

Significant improvements in physiological and psychological measures were observed, even at the large class sizes tested here, suggesting that TC has considerable potential as an economic, effective and convenient workplace intervention.

School playground surfacing and arm fractures in children: a cluster randomized trial comparing sand to wood chip surfaces

BACKGROUND

The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.

METHODS AND FINDINGS

The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04-6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7-21.4) for falls onto Fibar surfaces (p< or =0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26-15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1-30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.

CONCLUSIONS

Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02647424.

Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients

OBJECTIVE

Age-related patterns in postoperative pain are unclear with reports of no age differences and less pain with age. The objective of this study was to identify correlates of pain and intravenous patient-controlled analgesia (i.v. PCA) morphine use in younger and older patients.

DESIGN

24 hours after surgery, patients completed measures of pain intensity and pain qualities. Surgical factors, i.v. PCA morphine intake, anticholinergic load, polypharmacy, physical status, previous chronic and postoperative pain, and PCA experience were measured.

SETTING

Two academic general hospitals. PATIENTS. Two hundred forty-six general surgery patients ranging in age from 18 to 82 years old.

RESULTS

In older patients, higher pain scores were associated with female gender and previous experience of postoperative PCA. In younger patients, higher pain scores were associated with female gender, previous surgery without PCA, and greater morphine intake. Lower pain was associated with being male, and no previous surgical experience in older patients, and lower morphine intake in younger patients. Morphine intake was higher in patients who were younger, had better physical status, higher anticholinergic load, and experience with PCA. Among younger patients, increased morphine use also was associated with surgical procedure and duration. Higher pain scores were more strongly associated with morphine use among younger than older patients.

CONCLUSIONS

The correlates of postoperative pain and morphine use may differ with age, and the same factor may have different effects across age groups. Research is needed into the mechanisms of these age-specific profiles.

Injury risk from popular childhood physical activities: results from an Australian primary school cohort

BACKGROUND

Children engage in various physical activities that pose different injury risks. However, the lack of adequate data on exposure has meant that these risks have not been quantified or compared in young children aged 5-12 years.

OBJECTIVES

To measure exposure to popular activities among Australian primary school children and to quantify the associated injury risks.

METHOD

The Childhood Injury Prevention Study prospectively followed up a cohort of randomly selected Australian primary and preschool children aged 5-12 years. Time (min) engaged in various physical activities was measured using a parent-completed 7-day diary. All injuries over 12 months were reported to the study. All data on exposure and injuries were coded using the International classification of external causes of injury. Injury rates per 1000 h of exposure were calculated for the most popular activities.

RESULTS

Complete diaries and data on injuries were available for 744 children. Over 12 months, 314 injuries relating to physical activity outside of school were reported. The highest injury risks per exposure time occurred for tackle-style football (2.18/1000 h), wheeled activities (1.72/1000 h) and tennis (1.19/1000 h). Overall, boys were injured more often than girls; however, the differences were non-significant or reversed for some activities including soccer, trampolining and team ball sports.

CONCLUSION

Although the overall injury rate was low in this prospective cohort, the safety of some popular childhood activities can be improved so that the benefits may be enjoyed with fewer negative consequences.

Penetrating trauma in Ontario emergency departments: a population-based study

BACKGROUND

There is a paucity of population-based research on health service utilization related to penetrating trauma in Canada, even though such trauma can result in serious injury or death, and gunshot wounds have been labelled the "the new public health issue." Complete epidemiologic data, including emergency department (ED) visits and hospitalizations, for penetrating trauma is not available. The objective of this paper is to describe the epidemiology of ED visits for firearm-related and knife-related penetrating trauma in one Canadian province.

METHODS

All EDs in the province of Ontario (pop. approx. 12 400 000 at the time of the study) submit data on ED visits to the National Ambulatory Care Reporting System. This database includes patients' demographic information (i.e., age, sex and geographic area of residence), the reason for the visit, disposition (i.e., admitted to hospital or sent home), and other diagnostic information. For visits related to injuries, the cause of injury is also reported (e-codes according to the Canadian Enhancement to the International Statistical Classification of Diseases and Related Health Problems, 10th rev [ICD-10-CA]). All patients seen in Ontario EDs for an injury related to a firearm, knife, or sharp object, were included in our study.

RESULTS

Of the 1.2 million ED visits in 2002-03 for trauma in Ontario, 40 240 (3.4%) patients were treated for injuries relating to penetrating trauma. Most patients were male, and most were 15-24 years of age. Penetrating trauma was frequently a result of knives or sharp objects (39 654 visits or 98.5%); only 1.5% (n = 586) of these injuries were caused by firearms. Of those hospitalized, 151 were related to firearms and 1455 were related to knives/ sharp objects.

CONCLUSIONS

Analyzing administrative data provides an estimate of the impact of penetrating trauma on a population, thereby providing prevention programs with data upon which to design their strategies. Evidence-based prevention strategies are needed to reduce the burden of penetrating trauma. Monitoring ED and hospitalization data over time will help to assess trends and provide evidence for the effectiveness of such strategies.

Economic disparity in bicycle helmet use by children six years after the introduction of legislation

BACKGROUND

Studies evaluating the effectiveness of bicycle helmet legislation often focus on short term outcomes. The long term effect of helmet legislation on bicycle helmet use is unknown.

OBJECTIVE

To examine bicycle helmet use by children six years after the introduction of the law, and the influence of area level family income on helmet use.

METHODS

The East York (Toronto) health district (population 107,822) was divided into income areas (designated as low, mid, and high) based on census tract data from Statistics Canada. Child cyclists were observed at 111 preselected sites (schools, parks, residential streets, and major intersections) from April to October in the years 1995-1997, 1999, and 2001. The frequency of helmet use was determined by year, income area, location, and sex. Stratified analysis was used to quantify the relation between income area and helmet use, after controlling for sex and bicycling location.

RESULTS

Bicycle helmet use in the study population increased from a pre-legislation level of 45% in 1995 to 68% in 1997, then decreased to 46% by 2001. Helmet use increased in all three income areas from 1995 to 1997, and remained above pre-legislation rates in high income areas (85% in 2001). In 2001, six years post-legislation, the proportion of helmeted cyclists in mid and low income areas had returned to pre-legislation levels (50% and 33%, respectively). After adjusting for sex and location, children riding in high income areas were significantly more likely to ride helmeted than children in low income areas across all years (relative risk = 3.4 (95% confidence interval, 2.7 to 4.3)).

CONCLUSION

Over the long term, the effectiveness of bicycle helmet legislation varies by income area. Alternative, concurrent, or ongoing strategies may be necessary to sustain bicycle helmet use among children in mid and low income areas following legislation.

Compliance with the Australian national physical activity guidelines for children: relationship to overweight status

Childhood obesity incidence has increased substantially and it has been argued that decreasing physical activity levels, coinciding with an increase in sedentary behaviours, are responsible. Australian guidelines were published in 2004, recommending that children participate in a minimum of 60 min of physical activity daily and spend no more than 2h a day using electronic media for entertainment. We aimed to compare compliance with these guidelines amongst children of differing weight status. The Childhood Injury Prevention Study (CHIPS) collected data from a randomly selected sample of Brisbane primary and preschool children aged 5-12 years. The following data were available for 518 participants: age, gender, measured height and weight and estimated time per week from a parent-completed 7 days diary in physical activity out of school and sedentary leisure activities including television viewing and computer use. Using age standardised body mass index estimates, approximately 20% of the cohort were overweight. Non-compliance with guidelines was 14.7% for out of school physical activity participation, and 30.9% for excess electronic media entertainment use. There was a 63% increase in the odds of overweight status amongst children who were non-compliant with the electronic entertainment recommendations than those who were compliant (adjusted odds ratio=1.63; 95% CI=1.05-2.54). Female gender and school level socioeconomic category were also independently associated with overweight status. Non-compliance with the minimal physical activity guideline increased the odds of being overweight by 28%, however this difference was not statistically significant. One in seven children from the Greater Brisbane area are at risk for being insufficiently active whilst a third overuse electronic media. Given that overuse of electronic entertainment was positively associated with childhood obesity, these children should be the target of public health campaigns to promote alternative leisure time activities.

Quantifying the association between physical activity and injury in primary school-aged children

BACKGROUND

Regular physical activity is strongly advocated in children, with recommendations suggesting up to several hours of daily participation. However, an unintended consequence of physical activity is exposure to the risk of injury. To date, these risks have not been quantified in primary school-aged children despite injury being a leading cause for hospitalization and death in this population.

OBJECT

Our goal was to quantify the risk of injury associated with childhood physical activity both in and out of the school setting and calculate injury rates per exposure time for organized and non-organized activity outside of school.

METHODS

The Childhood Injury Prevention Study prospectively followed a cohort of randomly selected Australian primary school-and preschool-aged children (4 to 12 years). Over 12 months, each injury that required first aid attention was registered with the study. Exposure to physical activity outside school hours was measured by using a parent-completed 7-day diary. The age and gender distribution of injury rates per 10 000 hours of exposure were calculated for all activity and for organized and non-organized activity occurring outside school hours. In addition, child-based injury rates were calculated for physical activity-related injuries both in and out of the school setting.

RESULTS

Complete diary and injury data were available for 744 children. There were 504 injuries recorded over the study period, 396 (88.6%) of which were directly related to physical activity. Thirty-four percent of physical activity-related injuries required professional medical treatment. Analysis of injuries occurring outside of school revealed an overall injury rate of 5.7 injuries per 10000 hours of exposure to physical activity and a medically treated injury rate of 1.7 per 10000 hours.

CONCLUSION

Injury rates per hours of exposure to physical activity were low in this cohort of primary school-aged children, with <2 injuries requiring medical treatment occurring for every 10000 hours of activity participation outside of school.

Urban/rural variation in children's bicycle-related injuries

The objective of this study was to examine bicycle-related injury rates for children living in urban and rural areas. Data on all Canadian children hospitalised because of bicycling-related injuries (1994-1998) were obtained from the Canadian Institute for Health Information (CIHI). Injured children were classified as residing in urban, mixed urban, mixed rural or rural areas. Incidence rates for bicycle-related head injuries and other bicycle-related injuries were calculated. Logistic regression was used to estimate the odds of head injury, controlling for age, sex, socio-economic status (SES), collision with a motor vehicle, and the presence of provincial helmet legislation. In total, 9367 children were hospitalised for a bicycling-related injury over the 4-year-study period. Of these, 21% occurred in rural areas, 18% in mixed rural, 17% in mixed urban, while the remaining 44% occurred in urban areas. The average annual incidence rate for bicycle-related head injuries in children was 18.49 per 100000 for children living in rural areas compared with 10.93 per 100000 for those living in urban areas, 15.49 for children in mixed urban areas and 17.38 for children living in mixed rural areas. This variation may be explained by differences in bicycling exposure, helmet use, hospital admission criteria, or road environments across geographic areas.

Simulating Physiology and Methods for Therapeutic Evaluation with Emphasis on Hypertension

Improvements in therapy are aimed at better diagnosis and more effective treatment. The use of computer simulation has the potential to improve therapy in both ways. Computational methods have been used extensively in diagnosis, for interpreting MRI results, CAT scans and the development of treatments in the study of biochemical structure. The present review examines how simulation may be used to play a more fundamental role in therapeutic treatment often referred to as In Silico Biology. Simulation of cells, organs and systems, such as pulmonary and cardiovascular, can be used in clinical practice to improve diagnosis. Initially these developments will probably have to be refined before being used in general practice. However, when these simulations are linked with artificial intelligence techniques containing experimental databases then very powerful tools will result. The use of simulation in the design and development of new drugs can both be cost and time effective. Again, artificial intelligence techniques are likely to play an important role in evaluating patient risk factors and unwanted side effects.

Mechanism of Injury Affects 6-Month Functional Outcome in Children Hospitalized Because of Severe Injuries

BACKGROUND

The burden of childhood injury is often described using vital statistics for mortality and hospital admissions as a measure of morbidity. Hospital admissions, however, reflect the process of care and do not directly measure children's functional disability. The purpose of this study was to determine the influence of mechanism of injury on the functional outcome 6 months after injury in children in an inpatient trauma unit of a pediatric referral hospital.

METHODS

A retrospective cohort of 357 children aged 2 to 15 with an Injury Severity Score (ISS) > 12 was studied to determine the relationship between mechanism of injury (based on International Classification of Diseases, Ninth Revision e-code) and functional outcome 6 months after hospital discharge. Wee Functional Independence Measure (WeeFIM) was used to assess functional outcome. Any child with a WeeFIM score less than the maximum (of 126) attainable was classed as requiring assistance, and the relative risk of requiring assistance at 6 months was calculated for each injury mechanism. Poisson regression analysis was used to assess the importance of mechanism of injury, after adjusting for age, gender, ISS, and a primary diagnosis of central nervous system (CNS) injury.

RESULTS

Mechanism of injury had a significant effect on the functional outcome at 6 months: 72% of pedestrians, 64% of cyclists struck by cars, and 59% of injured motor vehicle occupants required assistance during daily activities. By contrast, only 27% of those injured playing sports and 22% of cyclists injured without motor vehicle involvement required assistance. The relative risk of children requiring assistance was similar with or without adjustment for age, gender, ISS, and CNS injury.

CONCLUSION

Mechanism of injury is significantly associated with requiring assistance 6 months postdischarge, even after controlling for age, injury severity, and the presence of a CNS injury. These data are important both when discussing the prognosis for an individual patient and also when considering the population impact of childhood injuries.

Impact of mandatory helmet legislation on bicycle-related head injuries in children: a population-based study

OBJECTIVE

Childhood bicycle-related head injuries can be prevented through the use of helmets. Although helmet legislation has proved to be a successful strategy for the adoption of helmets, its effect on the rates of head injury is uncertain. In Canada, 4 provinces have such legislation. The objective of this study was to measure the impact of helmet legislation on bicycle-related head injuries in Canadian children.

METHODS

Routinely collected data from the Canadian Institute for Health Information identified all Canadian children (5-19 years) who were hospitalized for bicycling-related injuries from 1994-1998. Children were categorized as head or other injury on the basis of International Classification of Diseases, Ninth Revision, codes. Rates of head injuries and other injuries were compared over time in provinces that adopted legislation and those that did not.

RESULTS

Of the 9650 children who were hospitalized because of a bicycle-related injury, 3426 sustained injuries to the head and face and the remaining 6224 had other injuries. The bicycle-related head injury rate declined significantly (45% reduction) in provinces where legislation had been adopted compared with provinces and territories that did not adopt legislation (27% reduction).

CONCLUSION

This country-wide study compared rates of head injury in regions with and without mandatory helmet legislation. Comparing head injuries with other non-head-injured children controlled for potential differences in children's cycling habits. The strong protective association between helmet legislation and head injuries supports the adoption of helmet legislation as an effective tool in the prevention of childhood bicycle-related head injuries.

Mandatory helmet legislation and children's exposure to cycling

BACKGROUND

Mandatory helmet legislation for cyclists is the subject of much debate. Opponents of helmet legislation suggest that making riders wear helmets will reduce ridership, thus having a negative overall impact on health. Mandatory bicycle helmet legislation for children was introduced in Ontario, Canada in October 1995. The objective of our study was to examine trends in children's cycling rates before and after helmet legislation in one health district.

SETTING

Child cyclists were observed at 111 preselected sites (schools, parks, residential streets, and major intersections) in the late spring and summer of 1993-97 and in 1999, in a defined urban community.

PARTICIPANTS

Trained observers counted the number of child cyclists. The number of children observed in each area was divided by the number of observation hours, resulting in the calculation of cyclists per hour.

MAIN OUTCOME MEASURE

A general linear model, using Tukey's method, compared the mean number of cyclists per hour for each year, and for each type of site.

RESULTS

Although the number of child cyclists per hour was significantly different in different years, these differences could not be attributed to legislation. In 1996, the year after legislation came into effect, average cycling levels were higher (6.84 cyclists per hour) than in 1995, the year before legislation (4.33 cyclists per hour).

CONCLUSION

Contrary to the findings in Australia, the introduction of helmet legislation did not have a significant negative impact on child cycling in this community.

A rapid procedure for initial drug evaluation

The overall aim of this work is to develop computer simulations to aid in the selection of proposed medicines and identify those most likely to succeed. One important feature is a systems approach to simulate both the target area with which the drug is designed to interact as well as the surrounding areas where feedback mechanisms may alter the expected effect. The simulation must be rapid if it is to be used to evaluate large numbers of potential drugs. Thus the procedure simplifies many of the known complex phenomena to provide a general framework and feedback mechanisms. An example of the use of the simulation to study a drug used to treat hypertension is given. A possible use of the technique is shown using the example of the effect of varying the drug dosage on the contraction of the arteriole muscle.

Forecasting patient services: a 21st century vision of an academic health centre

This article provides an overview of the development and implementation of the McGill University Health Centre model for forecasting patient services in the year 2004, and advice on how to apply the model. Critical success factors and case examples are highlighted. The insights provided will be of value to hospitals and other institutions that recognize the necessity of engaging in long-range planning and forecasting.