The Cellie Coping Kit for Children with Injury: Initial feasibility, acceptability, and outcomes

PURPOSE

Physical and psychological challenges can arise from paediatric injury, which can impact child health outcomes. Evidence-based resources to promote recovery are limited. The low cost, portable Cellie Coping Kit for Children with Injury provides evidence-based strategies to help children manage injury-related challenges. This study aimed to describe intervention feasibility and explore initial outcomes (learning, quality of life [QOL], and trauma symptoms).

METHODS

Three independent pilot studies were conducted. Child-parent dyads (n = 61) participated in the intervention; ~36% completed a 4-week follow-up assessment.

RESULTS

Results suggested that the intervention was feasible (e.g., 95% of parents would recommend the intervention; >85% reported that it was easy to use). Over 70% of participants reported learning new skills. No statistically significant differences were detected for children's QOL or trauma symptoms preintervention to postintervention.

CONCLUSION

Preliminary research suggests that the Cellie Coping Kit for Children with Injuries is a feasible, low-cost, preventive intervention, which may provide families with strategies to promote recovery from paediatric injury. Future research, including a randomized controlled trial, ought to further examine targeted long-term intervention outcomes.

Child coping, parent coping assistance, and post-traumatic stress following paediatric physical injury

BACKGROUND

Following a physical injury, many children exhibit long-term psychological reactions such as post-traumatic stress symptoms (PTSS). Children's coping strategies, and the ways that others help them cope with injury (i.e. coping assistance), are understudied, potentially malleable variables that could be targeted in preventive interventions. The objectives of the current research were to describe child coping behaviour and parent coping assistance following a child's injury, and to investigate the relationships among coping, coping assistance and child PTSS.

METHOD

Participants included 82 children with injuries and one parent of each child. Children completed measures of coping and coping assistance 2 weeks after their injury (T1). Children also completed measures of coping and PTSS at a 3-month follow-up (T2). Parents reported on the coping assistance they provided to their child at T1.

RESULTS

Children reported using an average of six coping strategies (out of 10) with wishful thinking, social support, distraction, and cognitive restructuring endorsed most frequently. Child-reported social withdrawal and resignation 2 weeks after his or her injury (T1) were related to subsequent PTSS (T2). Social withdrawal at T2 was related to concurrent child PTSS (T2). Children were more likely to seek social support when their parents reported helping their child cope. No relationships were identified between active coping behaviours or parent coping assistance and PTSS outcomes.

CONCLUSIONS

Findings suggest that children's coping strategies (particularly social withdrawal and resignation) play a possibly important, complex role in the development of traumatic stress symptoms. When parents help their child cope, children are more likely to seek out social support, suggesting that they will be more able to ask their parents for help as needed. Future research should identify effective strategies to prevent PTSS including how parents can best support their child following paediatric injury.

After the injury: initial evaluation of a web-based intervention for parents of injured children

The purpose of this study was to survey parent knowledge of child injury reactions (including post-traumatic stress symptoms) and to evaluate parent satisfaction and learning outcomes following a video- or web-based intervention. Fifty parents of children ages 6-17 years who were injured within the past 2 months were recruited from emergency and inpatient settings. A repeated-measures experimental design was employed in which participants were assigned to either a web-based or video intervention. Parent knowledge was assessed pre- and post-intervention. Learning outcomes and satisfaction were evaluated post-intervention. Parents showed high levels (∼70% accuracy) of knowledge about potential psychological injury reactions at baseline and post-intervention. In addition, post-intervention parents were able to generate new positive strategies to help their child recover and became more specific about types of reactions to monitor (e.g. avoidance). Participants reported high levels of satisfaction with both web and video interventions. While parents possess high levels of basic knowledge about child recovery from injury, the Web site and video tools provided concrete guidance that was useful in enhancing parent understanding of specific traumatic stress reactions to monitor in children post-injury.

Teen perceptions of good drivers and safe drivers: implications for reaching adolescents

OBJECTIVE

To understand definitions of the phrases "good driver" and "safe driver" among teen pre-drivers and early drivers in order to appropriately tailor messages about driving safety.

DESIGN

Qualitative study using freelisting, an anthropological research technique, to explore nuances in the ways that teens define a good driver and a safe driver

SETTING

Classes in six high schools each in a different state in the USA.

SUBJECTS

193 adolescent pre-drivers and early drivers, aged 15-17.

MAIN OUTCOME MEASURES

Meaning of the phrase good driver and safe driver was identified for subgroups of adolescents.

RESULTS

Teen pre-drivers and early drivers define a good driver and a safe driver as one who is cautious, alert, responsible, does not speed, obeys the law, uses seatbelts, and concentrates. There are subtle and potentially important differences in the way that subgroups define a good driver and a safe driver.

CONCLUSIONS

Injury prevention experts need to attend closely to the implicit meanings that teens attach to everyday terms. Freelisting is a method that identifies perceptions about the meaning of health communication messages and suggests differences in meaning among subgroups.

Emergency department screening for risk for post-traumatic stress disorder among injured children

OBJECTIVE

To discuss the successes and challenges associated with the implementation of a post-traumatic stress disorder (PTSD) screening tool in two pediatric emergency departments (ED).

METHODS

The STEPP screening tool has been developed previously on an inpatient population of motor vehicle trauma patients. It was applied here to the general ED population at two different pediatric trauma centers. Nurse screeners were trained and a convenience sample of patients with unintentional injuries who met study criteria were screened in the ED. Feedback from nurse screeners was obtained.

RESULTS

The process of implementing a screening tool to identify patients and their families significantly at risk for PTSD symptomatology presented some barriers, but overall acceptability of the process was high for both the emergency department staff and the patient. Recommendations for others considering implementation of screening programs in the ED are offered.

CONCLUSIONS

Future research using screening protocols in the ED should, in their design, attempt to capitalize on the successes identified in the current protocol and circumvent barriers also encountered.

Validation of simulated assessment of teen driver speed management on rural roads

More US teens die from traffic crashes than from any other cause, with speed and rural roads major contributing factors. This study aimed to validate a high-fidelity simulator to explore these risks in an injury-free environment. Twenty-one newly-licensed 16-year-old males completed simulated and on-the-road drives of the same rural roads. Average free speeds on three road segments showed no systematic differences across segments. The majority of teens exhibited speeds in the simulator within 10% of those on-the-road. These findings validate the simulator for further research on teen driver free speeds on rural roads. Further analyses are needed to validate other performance measures.

Competent independent driving as an archetypal task of adolescence

Supplement Editor, Dr Flaura K Winston, and Co-Editor, Dr Teresa Senserrick, introduce 10 papers covering the current science of safe driving among adolescents from the varied viewpoints of an international panel of experts. This Expert Panel, convened by the Center for Injury Research and Prevention (formerly TraumaLink) at the Children's Hospital of Philadelphia and State Farm Insurance Companies(R), working jointly on the Youthful Driver Research Initiative, represents a wide range of expertise, thereby providing a broad understanding of driving, adolescence, and adolescent driving.

Trip characteristics of vehicle crashes involving child passengers

OBJECTIVES

To describe the trip characteristics of vehicle crashes involving children, and to examine the effect of situational factors on front row seating or inappropriate restraint for young children.

METHODS

A cross sectional study was conducted on children <16 years in crashes of insured vehicles in 15 US states, with data collected using insurance claims records and a telephone interview. A descriptive analysis of the characteristics of vehicle crashes involving children was performed. Multivariate Poisson regression was used to identify situational factors associated with inappropriate restraint or front row seating.

RESULTS

These data suggest that children were traveling in vehicles involved in crashes that occurred under usual driving circumstances-that is, closer to home (60%), on a local road (56%), during normal daytime hours (71%), within areas with relatively lower posted speed limits (76%). Compared with children involved in morning crashes, those in daytime crashes (RR = 1.65, 95% CI 1.13 to 2.49) or in night-time crashes (RR = 1.63, 95% CI 1.09 to 2.67) were more likely to be sitting in the front seat. Children involved in night-time crashes were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.01 to 1.22) than those in daytime crashes. Children riding with two or more additional passengers were more likely to be inappropriately restrained (RR = 1.12, 95% CI 1.02 to 1.27) than those with no other passengers.

CONCLUSIONS

Educational initiatives should aim to increase the perception that parents have about the potential crash risk of everyday trips. Some situational characteristics of trips were associated with inappropriate restraint and front row seating behaviors for young children.

Teen drivers and the risk of injury to child passengers in motor vehicle crashes

OBJECTIVES

The first aim was to examine the relationship between driver's age (novice teens, older teens, and adults) and child passenger's restraint status, front row seating, and injury risk. The second aim was to explore whether there was an excess injury risk to child passengers in teen crashes compared to those in adult crashes by examining the contributing factors.

METHODS

A cross sectional study involving telephone interviews with insured drivers in a probability sample of 12 163 crashes involving 19 111 children was conducted. Sequential logistic regressions were employed.

RESULTS

Among child passengers aged 4-8, appropriate restraint was <1% for novice teens, 4.5% for older teens, and 23.6% for adults. Front row seating for children <13 years was more common in the novice teen group (26.8%) than in the other two groups. Compared with children riding with adults, those with both teen groups experienced excess injury risk. After adjusting for crash severity, there was a 43% reduction in the odds ratio (OR) for novice teens (OR 1.58, 95% confidence interval (CI) 1.14 to 2.19) and a 24% reduction for older teens (OR 2.15, 95% CI 1.42 to 3.26). After adjusting for vehicle type, child's restraint status and front row seating, there was a further 19% reduction in the OR for novice teens (OR 1.37, 95% CI 1.00 to 1.88) and a further 13% reduction for older teens (OR 1.74, 95% CI 1.14 to 2.66).

CONCLUSION

These findings suggest ways in which graduated driver licensing laws may be further enhanced to better protect child passengers from the excess injury risk associated with teen crashes.

Rear seating and risk of injury to child occupants by vehicle type

The safety of rear-seated child passengers was evaluated across vehicle types. 113,887 children under age 16 in crashes were enrolled as part of an on-going crash surveillance system which links insurance claims data to telephone survey and crash investigation data. Children in the second row suffered less significant injuries than those in the front in all vehicle types except compact extended cab pickup trucks in which the risk for children in the rear was 13% as compared to 2.8% for front-seated occupants. Further research is needed to identify the child and vehicle characteristics which might explain this increased injury risk.

The effect of seating position on risk of injury for children in side impact collisions

The objective of this study was to evaluate the effect of seating position on risk of injury to children in side impact crashes. 5,632 children under age 16 in side impact crashes were enrolled as part of an on-going crash surveillance system which links insurance claims data to telephone survey and crash investigation data. Children seated in the front seat were at higher risk of significant injury than children seated in the rear (OR = 2.2 95% CI (1.2-3.8)). After adjusting for age, restraint use, and vehicle damage, children in the front seat were more likely to be injured (OR 2.6 95% CI (1.1-6.2)) than children seated in the rear when the child was sitting near the side of the impact. These results highlight the importance of evaluating the safety performance of both vehicles and restraint systems for children in side impact crashes.

Exposure to traffic among urban children injured as pedestrians

OBJECTIVES

To explore the immediate pre-crash activities and the routine traffic exposure (street crossing and play) in a sample of urban children struck by automobiles. In particular, the traffic exposure of children who were struck while playing was compared with that of those struck while crossing streets.

DESIGN

Cross sectional survey.

SETTING

Urban pediatric emergency department.

PATIENTS

A total of 139 children ages 4-15 years evaluated for acute injuries resulting from pedestrian-motor vehicle collisions during a 14 month period.

MAIN OUTCOME MEASURES

Sites of outdoor play, daily time in outdoor play, weekly number of street crossings, pre-crash circumstance (play v walking).

RESULTS

Altogether 39% of the children routinely used the street and 64% routinely used the sidewalks as play areas. The median number of street crossings per week per child was 27. There were no differences in exposures for the 29% who were hit while playing compared with the 71% who were hit while walking. Although 84% of the children walked to or from school at least one day per week, only 15% of the children were struck while on the school walking trip. The remainder were injured either while playing outdoors or while walking to other places.

CONCLUSIONS

Urban children who are victims of pedestrian crashes have a high level of traffic exposure from a variety of circumstances related to their routine outdoor playing and street crossing activities. The distributions of traffic exposures were similar across the sample, indicating that the sample as a whole had high traffic exposure, regardless of the children's activity preceding the crash. Future pedestrian injury programs should address the pervasive nature of children's exposure to traffic during their routine outdoor activities.

Child bicyclist injuries: are we obtaining enough information in the emergency department chart?

OBJECTIVE

The purpose of this study was to assess the range of information relevant to bicyclist injury research that is available on routinely completed emergency department medical records.

METHODS

A retrospective chart review of emergency department medical records was conducted on children who were injured as bicyclists and treated at an urban level I pediatric trauma center. A range of variables relevant to bicyclist injury research and prevention was developed and organized according to the Haddon matrix. Routinely completed free text emergency department medical records were assessed for the presence of each of the targeted elements. In addition, medical records of seriously injured patients (for whom a more structured medical record is routinely used) were compared to free form records of less seriously injured patients to identify differences in documentation that may be related to the structure of the medical record.

RESULTS

Information related to previous medical history (96% of records), diagnosis (89%), documentation of pre-hospital care (82%), and child traumatic contact points (81%) were documented in the majority of medical records. Information relevant to prevention efforts was less commonly documented: identification of motor vehicle/object involved in crash (58%), the precipitating event (24%), the location of the crash (23%), and documentation of helmet use (23%). Records of seriously injured patients demonstrated significantly higher documentation rates for pre-hospital care and child traumatic contact points, and significantly lower documentation rates for previous medical history, child kinematics, main body parts impacted, and location of injury event.

CONCLUSIONS

Routinely completed free text emergency department medical records contain limited information that could be used by injury researchers in effective surveillance. In particular information relating to the circumstances of the crash event that might be used to design or target prevention efforts is typically lacking. Routine use of more structured medical records has the potential to improve documentation of key information.

Trends in booster seat use among young children in crashes

INTRODUCTION

Booster seat use in the United States is extremely low among 4- to 8-year-old children, the group targeted for their use. However, more recent attention has been paid to the role of booster seats for children who have outgrown their forward-facing child safety seat. In particular, several states are currently considering upgrades to their child restraint laws to include the use of booster seats for children over 4 years of age.

OBJECTIVE

To examine recent trends in booster seat use among children involved in automobile crashes in 3 large regions of the United States.

DESIGN

This study was performed as part of the Partners for Child Passenger Safety project, an ongoing, child-specific crash surveillance system that links insurance claims data to telephone survey and crash investigation data. All crashes occurring between December 1, 1998, and November 30, 2000, involving a child occupant between 2 to 8 years of age riding in a model year 1990 or newer vehicle reported to State Farm Insurance Companies from 15 states and Washington, DC, were eligible for this study. A probability sample of eligible crashes was selected for a telephone survey with the driver of the vehicle using a previously validated instrument. The study sample was weighted according to each subject's probability of selection, with analyses conducted on the weighted sample.

RESULTS

The weighted study sample consisted of 53 834 children between 2 to 8 years old, 11.5% of whom were using a booster seat at the time of the crash. Booster seat use peaked at age 3 and dropped dramatically after age 4. Over the period of study, booster seat use among 4- to 8-year-olds increased from 4% to 13%. Among 4-year-olds specifically, booster use increased from 14% to 34%. Among children using booster seats, approximately half used shield boosters and half used belt-positioning boosters.

CONCLUSIONS

Although overall booster seat use among the targeted population of 4- to 8-year-old children remains low, significant increases have been noted among specific age groups of children over the past 2 years. These data may be useful to pediatricians, legislators, and educators in efforts to target interventions designed to increase appropriate booster seat use in these children.

Protecting the child's abdomen: a retractable bicycle handlebar

A surveillance system in the Emergency Department of a level 1 pediatric trauma center previously identified minor bicycle crashes as a cause of serious child abdominal injury. A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. The objective of this work was to redesign the bicycle handlebar to reduce the forces transmitted to the child's abdomen during an impact with the handlebars. A retractable handlebar consisting of a spring-mass-damper system was designed to retract and absorb the majority of energy at impact (Patent pending). Because the child remains in contact with the bar after impact, the retracting system also includes a mechanism to damp the outward motion of the handlebar. This prototype will reduce the forces at impact by approximately 50% in a collision similar to those discussed above. A unique methodology of translating research findings into product design produced a novel handlebar that absorbs significant energy that otherwise would be transferred to the child's abdomen when impacting the handlebar.

Factors influencing pediatric injury in side impact collisions

BACKGROUND

Side impact collisions pose a great risk to children in crashes, but information about the injury mechanisms is limited.

METHODS

This study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large, child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions.

RESULTS

Ninety-three children in 55 side impact crashes were studied. Twenty-three percent (n = 22) of the children received an Abbreviated Injury Scale (AIS) score > or = 2 (clinically significant) injury. In these 22 children, head (40%), extremity (23%), and abdominal injuries (21%) were the most common significant injuries. Cases that illustrate body region-specific injury mechanisms are discussed.

CONCLUSION

The cases revealed that serious injuries, particularly head injuries, occur even in minor crashes, and efforts should be made to make the interiors of vehicles more child occupant friendly. Lower extremity and abdominal injuries occurred because of contact with the intruding door. Design of vehicles to minimize crush should mitigate the occurrence and severity of these injuries.

Partners for child passenger safety: a unique child-specific crash surveillance system

Insurance claims data were combined with telephone survey and on-site crash investigation data to create the first large scale, child-focused motor vehicle crash surveillance system in the US. Novel data management and transfer techniques were used to create a nearly real-time data collection system. In the first year of this on-going project, known as Partners for Child Passenger Safety, over 1200 children < or = 15 years of age per week were identified in crashes reported to State Farm Insurance Co. from 15 states and Washington, D.C. Partners for Child Passenger Safety is similar in its design and overall objectives to National Automotive Sampling System (NASS), the only other population-based crash surveillance system currently operating in the US.

Misuse of booster seats

OBJECTIVE

To describe several aspects of booster seat use and misuse in a sample of children attending child safety seat clinics.

METHODS

Booster seat practices were assessed at 76 child safety seat clinics held between April 1997 and January 1999 in Pennsylvania and southern New Jersey. At each assessment, a child passenger safety team evaluated the booster seat and identified modes of misuse.

RESULTS

Altogether 227 booster seats were observed. Sixty eight per cent (68%) of shield boosters and 20% of belt positioning boosters were misused. Thirty two per cent of the children using a shield booster weighed more than 40 lb (18.1 kg); 68% of children in shield boosters and 63% in belt positioning boosters weighed less than 40 lb.

CONCLUSION

This study identified a relatively high rate of booster seat misuse. Shield boosters were more likely to be misused than belt positioning booster seats. Significant numbers of children weighing more than 40 lb were using possibly dangerous shield boosters. The majority of children in this study were less than 40 lb. In this weight range, a convertible child restraint system provides better protection than a booster seat. Booster seat use should only be initiated once the child has completely outgrown their convertible child restraint system.

When "buckle up" is not enough: enhancing the safety of children in motor vehicles

Motor vehicle crashes are the leading cause of death and acquired disability in children over age 1 in the United States. In 1998 alone, 697 children under age 6 died as occupants in motor vehicles, and nearly 100,000 were injured. This Issue Brief describes findings from Partners for Child Passenger Safety, the nation's largest surveillance system of children in car crashes, and points to improvements in child restraints that can reduce the risk of serious injury in the event of a crash.

Assessing child restraint misuse by parental survey

OBJECTIVE

To determine the extent to which child restraint system (CRS) misuse can be evaluated by parental survey.

METHODS

A cross sectional survey was conducted at eight CRS clinics from May to October, 1998. Before CRS inspection, parents were administered a structured interview to identify distinct characteristics of restraint use and misuse. After the interview, a certified child passenger safety technician team independently evaluated the restraint system and identified specific modes of misuse. Parent descriptions of CRS use were compared with observations of the technician and the degree of agreement between the two was assessed for several specific attributes of use.

RESULTS

A total of 100 children restrained in convertible CRSs were included in the study. Parents were able to accurately report several aspects of child restraint use-in particular, the attachment and fit of the CRS, the use of the harness clip, and the CRS incline. Parents were less accurate in their characterization of the fit of the child in the CRS. For nearly every item assessed, parents were more accurate in their description of correct compared with incorrect use.

CONCLUSIONS

Interview tools can be developed that enable parents to describe aspects of CRS use and that screen for correct CRS use. These tools could be administered by telephone to obtain a more representative estimate of the prevalence of CRS misuse or to screen for CRS misuse. This screening would assist in targeting time consuming and costly CRS clinics to those parents who need them the most.

The danger of premature graduation to seat belts for young children

OBJECTIVE

To determine the risk of significant injury associated with premature graduation of young (2- to 5-year-old) children to seat belts from child restraint systems (CRS).

BACKGROUND

Advocates recommend use of child safety seats for children younger than age 4 and booster seats for children age 4 and older. Despite these recommendations, many children are prematurely taken out of these child restraints and placed in seat belts. Although data exist to support the use of child restraints over nonrestraint, no real-world data exist to evaluate the risk of significant injury associated with premature use of seat belts.

DESIGN/METHODS

Partners for Child Passenger Safety includes a child-focused crash surveillance system based on a representative sample of children ages 0 to 15 years in crashes involving 1990 and newer vehicles reported to State Farm Insurance Companies in 15 states and the District of Columbia. Driver reports of crash circumstances and parent reports of child occupant injury were collected via telephone interview using validated surveys. Results were weighted based on sampling frequencies to represent the entire population.

RESULTS

Between December 1, 1998, and November 30, 1999, 2077 children aged 2 to 5 years were included and were weighted to represent 13 853 children. Among these young children, 98% were restrained, but nearly 40% of these children were restrained in seat belts. Compared with children in CRS, children in seat belts were more likely to suffer a significant injury (relative risk: 3.5; 95% confidence interval: [2. 4, 5.2]). Children in seat belts were at particular risk of significant head injuries (relative risk: 4.2; 95% confidence interval: [2.6, 6.7]) when compared with children in CRS.

CONCLUSIONS

Premature graduation of young children from CRS to seat belts puts them at greatly increased risk of injury in crashes. A major benefit of CRS is a reduction in head injuries, potentially attributable to a reduction in the amount of head excursion in a crash.

The learning classifier system: an evolutionary computation approach to knowledge discovery in epidemiologic surveillance

The learning classifier system (LCS) integrates a rule-based system with reinforcement learning and genetic algorithm-based rule discovery. This investigation reports on the design, implementation, and evaluation of EpiCS, a LCS adapted for knowledge discovery in epidemiologic surveillance. Using data from a large, national child automobile passenger protection program, EpiCS was compared with C4. 5 and logistic regression to evaluate its ability to induce rules from data that could be used to classify cases and to derive estimates of outcome risk, respectively. The rules induced by EpiCS were less parsimonious than those induced by C4.5, but were potentially more useful to investigators in hypothesis generation. Classification performance of C4.5 was superior to that of EpiCS (P<0.05). However, risk estimates derived by EpiCS were significantly more accurate than those derived by logistic regression (P<0.05).

Actions without consequences: injury-related messages in children's programs

OBJECTIVE

To characterize children's television programs in terms of their unintentional injury-related messages.

DESIGN

Content analysis. Episodes representing a total of 216 unique television programs were coded for the presence of imitable unsafe behaviors without consequences.

SETTING

A census of all children's programming airing in a northeastern city during the first week of December 1996.

RESULTS

Exactly 47.0% of children's programming depicted at least 1 instance of unsafe, imitable behavior without consequences; one third had more than 3 instances. Exactly 51.0% of the programs targeted to school-age children and 33.4% of the programs targeted to preschoolers contained these unsafe behaviors. The majority (56.8%) of children's programs on basic cable television depicted unsafe behavior as compared with 23.1% of programs shown on public television. Cartoon programs depicted the most unsafe behaviors (60.3%), as compared with live-action programs (33.4%) and other genres (23.3%).

CONCLUSIONS

Children's television programs depict too many unsafe behaviors without consequences. Future work should explore the role of these programs in the development of unsafe behaviors in children.

Discovery of predictive models in an injury surveillance database: an application of data mining in clinical research

A new, evolutionary computation-based approach to discovering prediction models in surveillance data was developed and evaluated. This approach was operationalized in EpiCS, a type of learning classifier system specially adapted to model clinical data. In applying EpiCS to a large, prospective injury surveillance database, EpiCS was found to create accurate predictive models quickly that were highly robust, being able to classify > 99% of cases early during training. After training, EpiCS classified novel data more accurately (p < 0.001) than either logistic regression or decision tree induction (C4.5), two traditional methods for discovering or building predictive models.

Factors influencing pediatric injury in side impact collisions

Side impacts collisions pose a great risk to children in crashes but information about the injury mechanisms is limited. The heights and weights of children vary widely and as a result, the injury patterns may vary across the pediatric age range. This study involves a case series of children in side impact collisions who were identified through Partners for Child Passenger Safety, a large child-focused crash surveillance system. The aim of the current study was to use in-depth crash investigations to identify injury mechanisms to children in side impact collisions. 93 children in 55 side impact crashes were studied. 23% (n = 22) of the children received an AIS > or = 2 (clinically significant) injury. In these 22 children, head (39%), extremity (22%), and abdominal injuries (17%) were the most common significant injuries. The cases revealed that serious injuries occur even in minor crashes. Cases that illustrate body region-specific injury mechanisms are discussed.

Who can give a pediatric trauma history for children injured in bicycle crashes?

Emergency Departments are important sites for injury surveillance but the quality of data collected has not been evaluated. This prospective cohort study assessed the ability of various respondents to provide circumstantial information following pediatric bicyclist trauma. A semi-structured survey tool was administered in the Emergency Department of a Level One Pediatric Trauma Center for 448 child bicyclists. The injured child provided more complete information when compared to witnesses and Emergency Medical Services personnel. No one respondent type provided the complete history. To obtain thorough injury circumstantial information, multiple respondents should be interviewed utilizing a semi-structured questionnaire.

Looking beyond the physical injury: posttraumatic stress disorder in children and parents after pediatric traffic injury

BACKGROUND

Traffic crashes are the leading health threat to children in the United States, resulting in nearly 1 million injuries annually. The psychological consequences of these injuries are primarily unknown. The aims of this study were to estimate the prevalence of posttraumatic stress disorder (PTSD) in traffic-injured children and their parents and to identify risk factors for PTSD development.

METHODS

A prospective cohort study of traffic-injured children between 3 and 18 years of age was conducted at a level 1 Pediatric Trauma Center. The children were enrolled as part of an ongoing surveillance system of traffic-related injuries. Presence and severity of PTSD were determined in the children and their parents through a validated diagnostic questionnaire 7 to 12 months after child injury.

RESULTS

Twenty-five percent of the children and 15% of the parents suffered diagnostic PTSD, but only 46% of the parents of affected children sought help of any form (including from friends) for their child and only 20% of affected parents sought help for themselves. Child PTSD was associated with older child age and parent PTSD. Parent PTSD was associated with younger child age, child PTSD, and parent witnessing the event. Injury severity was not predictive of PTSD.

CONCLUSIONS

PTSD in children and their parents is a common, yet overlooked, consequence of pediatric traffic-related injury with prevalence rates similar to those found in children exposed to violence. Physicians managing the pediatric trauma patient, regardless of injury severity or whether the injury was intentional, should screen for PTSD and refer for treatment where appropriate.

The carnage wrought by major economic change: ecological study of traffic related mortality and the reunification of Germany

OBJECTIVE

To document the effects of sudden economic change on death rates for occupants of cars in the former German Democratic Republic (East Germany).

DESIGN

Ecological time series study of East Germany in comparison with the former Federal Republic of Germany (West Germany) before and after reunification in 1990.

SETTING

East and West Germany from 1985 to 1996.

SUBJECTS

Populations of East and West Germany between 1985 and 1996.

MAIN OUTCOME MEASURES

Death rates for occupants of cars.

RESULTS

After the reunification of Germany, East Germany experienced a sudden, temporary affluence and a concomitant fourfold increase in death rates for car occupants between 1989 and 1991. Although death rates increased in all age groups, young adults (aged 18-24) were most affected. The death rate per 100 000 population for those aged 18-20 years increased 11-fold between 1989 and 1991; for those aged 21-24 years the increase was eightfold.

CONCLUSION

A tragic consequence of the reunification of Germany was a dramatic increase in the death rate for car occupants. Sudden economic change and availability of cars resulted in both a rise in vehicle ownership and an increase in the number of inexperienced drivers on roads that were ill prepared for the increased traffic. The lesson learnt from Germany is that during times of economic change and modernisation, measures to prevent the predictable injury deaths that will result need to be considered.

Development and validation of the injury severity assessment survey/parent report: a new injury severity assessment survey

OBJECTIVE

To develop and pilot test a telephone-based survey instrument that enables parents to identify and characterize the body region and severity of childhood injuries using the Abbreviated Injury Scale (AIS) scoring system.

DESIGN

A prospective cross-sectional survey.

SETTING

The emergency department of an urban, tertiary care, pediatric trauma center.

PARTICIPANTS

One hundred forty-seven parents of children younger than 18 years and seen in the emergency department for acute treatment of an unintentional injury.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The degree of agreement, measured as sensitivity, specificity, and kappa statistic, between medical record information and parents' responses to the telephone survey regarding the identification and characterization of clinically significant (AIS > or =2) injuries.

RESULTS

The survey, known as the Injury Severity Assessment Survey/Parent Report, was developed via a systematic review of the AIS 1990 manual. Answers to questions were developed in a way that enabled automated coding of responses into AIS scores or ranges of scores. The sensitivity of the survey (its ability to detect injuries scoring 2 or more on the AIS that were documented in the medical record) varied somewhat by the body region of injury, ranging from 88% for head, face, neck, and spine injuries to 95% for extremity injuries. Intermediate sensitivity (92%) was noted for the detection of significant chest and abdomen injuries. The specificity of the survey (its ability to rule out the presence of a significant injury when one was not documented in the medical record) was more than 95% in each of the 3 body region groups. The kappa statistics for the 3 body region groups ranged from 0.89 to 0.92.

CONCLUSIONS

A new telephone-based survey has been developed that enables parents to characterize their child's injuries by body region and to differentiate between minor injuries and more significant injuries using a well-established injury classification system. This survey has a significant advantage over previous telephone-based or written surveys of childhood injuries and may be particularly valuable in population-based (e.g., random-digit dial surveys) or multi-institutional studies of pediatric injuries.

Hidden spears: handlebars as injury hazards to children

OBJECTIVES

To delineate the mechanism of serious bicycle handlebar-related injuries in children and make recommendations for preventive strategies.

METHODS

Prospective cross-sectional surveillance system of seriously injured child bicyclists supplemented by in-depth, on-site crash investigation to delineate specific injury mechanisms. Interdisciplinary analyses involved engineers, clinicians, epidemiologists, and biostatisticians.

SETTING

The emergency department and in-patient trauma service of an urban level one pediatric trauma center between October 1995 and September 1997.

PARTICIPANTS

Patients under 18 years of age who were treated for serious bicycle-related injuries (Abbreviated Injury Scale scores of 2 or greater).

RESULTS

The surveillance system identified two distinct circumstances for serious child bicyclist injury: 1) handlebar-related injuries associated with minor incidents (falls from bicycles) and 2) nonhandlebar-related injuries associated with severe incidents (bicycle-motor vehicle crashes). Crash investigations explored the minor incidents that resulted in serious handlebar-associated injuries. In the typical mechanism, as the child lost control of the bicycle and began to fall, the front wheel rotated into a plane perpendicular to the child's body. The child then landed on the end of the handlebar resulting in serious truncal injuries.

CONCLUSIONS

A discordancy exists between the apparently minor circumstances and serious injuries sustained by child bicyclists who impact bicycle handlebars. Recognition of the mechanism of handlebar-related injuries might aid the practitioner in early diagnosis of serious abdominal injuries in child bicyclists. This injury mechanism may be avoided through bicycle redesign that would involve both limiting rotation of the front wheel and modifying the ends of handlebars. An integrated approach involving a surveillance system to identify an injury hazard supplemented by in-depth, on-site crash investigations effectively provided the detailed mechanism of injury needed to develop interventions.

Severe head injury caused by airbag deployment

Passenger-side airbags are present in over 21 million automobiles and will be required on all passenger vehicles by the model year 1999. Although airbags are effective supplemental restraint systems and have saved over 1,500 lives, airbag-related injuries have been reported. The National Highway Traffic Safety Administration recently reported 15 child deaths caused by airbag deployment. All of these children were believed to be improperly restrained in the front passenger position of a car equipped with a passenger-side airbag. This case represents the first serious injury caused by airbag deployment in a child that was properly positioned in an approved child restraint.

Lethal airbag injury in an infant

Airbag injuries to automobile passengers are increasing in frequency, but the majority of reported injuries have been relatively minor and have occurred in adults. The National Highway Traffic Safety Administration (NHTSA) has identified a potentially lethal injury mechanism that occurs when safety seats are placed rear-facing on the passenger side of a vehicle equipped with a passenger side airbag. We report the first case of infant fatality resulting from passenger side airbag deployment that validates this mechanism.

Biomechanical epidemiology: a new approach to injury control research

Injury control studies, from inception and design to dissemination of results, tend to remain within individual discipline. This is largely because each of the disciplines has a unique language and approach to research. Collaborative research is often performed serially with one discipline presenting the results of that discipline's studies to another discipline. Epidemiologists and clinicians tell engineers to design a safety technology to prevent a specific injury. Engineers tell lawyers what is feasible to include in standards. As a result, epidemiological studies lack mechanical data needed by the engineers and engineering studies lack generalizability. The procedure for incorporating the best of multiple disciplines throughout the performance of injury control studies has not existed until recently and is presented conceptually in this manuscript. This new approach, Biomechanical Epidemiology, is an exciting enhancement to current injury control research.

An analysis of the time-dependent changes in intracellular calcium concentration in endothelial cells in culture induced by mechanical stimulation

When bovine pulmonary artery endothelial cells in culture are subjected to mechanical strain, their physiology is altered. Experimentally, this mechanical strain is generated by increased tension in the substrate to which the cells are attached and results in altered levels of fibronectin. Studies of the structural response of the endothelial cell suggest that this stimulus is transmitted to the cell membrane, organelles, and cytoskeleton by natural cell attachments in a quantifiable and predictable manner. This report examines altered intracellular calcium homeostasis as a possible messenger for the observed strain-induced physiologic response. In particular, using the intracellular trapped calcium indicator dyes, Quin2 and Fura2, we observed changes in cytosolic free calcium ion concentration in response to biaxial strain of bovine pulmonary artery endothelial cells in culture. The magnitude and time course of this calcium transient resemble that produced by treatment with the calcium ionophore, Ionomycin, indicating that mechanical stimulation may alter cell membrane permeability to calcium. Additional experiments in the presence of EDTA indicated that calcium was also released from intracellular stores in response to strain. In order to explain the stretch-induced calcium transients, a first-order species conservation model is presented that takes into account both the cell's structural response and the calcium homeostatic mechanisms of the cell. It is hypothesized that the cell's calcium sequestering and pumping capabilities balanced with its mechanically induced changes in calcium ion permeability will determine the level and time course of calcium accumulation in the cytosol.

A system to reproduce and quantify the biomechanical environment of the cell

An in vitro system that permits application of a uniform biomechanical stimulus to a population of cells with great precision has been developed. The device is designed to subject living cells to reproducible and quantifiable biaxial strains from 0 to 10% at rates from quasi-static to 1 s-1 and frequencies from 0 to 5 Hz. Equations for determining the strain in the substrate upon which the cells are grown, based on easily measured parameters, are derived and validated experimentally. The mechanical properties of the substrate are determined, and it is demonstrated that cells can easily be cultured in the apparatus. By use of the system, cloned bovine pulmonary artery endothelial cell clones are subjected to 5% biaxial strains applied at a peak strain rate of 0.5 s-1 and a frequency of 1 Hz for 7 h with cell viability greater than 84% and cell detachment less than 8%. We demonstrate that cells must be attached to the substrate for them to be stretched and that cell strain and substrate strain are not equal. With the use of fluorescently labeled beads as cell surface markers to measure the actual strain produced in the cells as a result of the deformation of the substrate, cell elongation was found to be approximately 60% of the strain in the substrate. This constant appeared to be affected by both in vitro cell age and morphology.

Effects of biaxial deformation on pulmonary artery endothelial cells

An apparatus has been designed to subject vascular cells grown on a compliant substrate in vitro to uniform, quantifiable levels of biaxial deformation. The system described can be controlled with respect to strain level, rate, and frequency to mimic the pulsatile force to which vascular cells are exposed in vivo under both physiologic and pathologic conditions. In the experiments presented here, bovine pulmonary artery endothelial cells were grown on a substrate of segmented polyurethane urea (Mitrathane). Cell growth and morphology on this substrate were compared with those of cells grown on standard tissue culture polystyrene with no difference noted between the two substrates. Primary cultures of pulmonary artery endothelial cells were seeded onto Mitrathane, which was then subjected to cyclic biaxial deformation-producing strains of 0.78%, 1.76%, 4.9%, or 12.5% at a frequency of 1 sec-1 and a duty cycle of 0.5 sec-1 for 7 h. Cells subjected to deformations generating strains of either 4.9% or 12.5% secreted significantly less fibronectin than nondeformed cells. Similar results were obtained in experiments using cloned pulmonary artery endothelial cells on Mitrathane subjected to the 4.9% strain; however, total protein synthesis was increased. Cell viability and DNA synthesis were not affected by cyclic biaxial deformation in these experiments.