Ecological level analysis of the relationship between smoking and residential-fire mortality.

OBJECTIVES: To examine the association between tobacco smoking and residential-fire mortality and to investigate whether this association is explained by the confounding effects of selected socioeconomic factors (ie, educational attainment and median household income). DESIGN: An ecological analysis relating state-level residential-fire mortality to state-level percentages of adults who smoke was conducted. Negative binomial rate regression was used to model this relationship, simultaneously controlling for the selected socioeconomic factors. RESULTS: After educational attainment and median household income had been controlled for, smoking percentages among adults correlated significantly with state-level, population-based residential-fire mortality (estimated relative rate for a 1% decrease in smoking = 0.93; 95% CI 0.89 to 0.97). CONCLUSIONS: Mortality from residential fires is high in states with high smoking rates. This relationship cannot be explained solely by the socioeconomic factors examined in this study.

The foot of Homo naledi.

Modern humans are characterized by a highly specialized foot that reflects our obligate bipedalism. Our understanding of hominin foot evolution is, although, hindered by a paucity of well-associated remains. Here we describe the foot of Homo naledi from Dinaledi Chamber, South Africa, using 107 pedal elements, including one nearly-complete adult foot. The H. naledi foot is predominantly modern human-like in morphology and inferred function, with an adducted hallux, an elongated tarsus, and derived ankle and calcaneocuboid joints. In combination, these features indicate a foot well adapted for striding bipedalism. However, the H. naledi foot differs from modern humans in having more curved proximal pedal phalanges, and features suggestive of a reduced medial longitudinal arch. Within the context of primitive features found elsewhere in the skeleton, these findings suggest a unique locomotor repertoire for H. naledi, thus providing further evidence of locomotor diversity within both the hominin clade and the genus Homo.

The Winnicott Squiggle Game: a vehicle for communicating with the school-aged child.

The Squiggle Game, described by pediatrician/child psychiatrist D. W. Winnicott, is a pencil-and-paper technique for eliciting children's thoughts and feelings. Unlike drawing tests such as the Goodenough Draw-A-Person Test and the Bender-Gestalt Form Copying Test, the Squiggle Game has an entirely unstructured format. This allows maximal latitude for children to share ideas and feelings. Also, participation by the physician makes the approach fun, rather than simply another test or chore for the child. The Squiggle Game has wide applicability in the general practice of pediatrics. It is ideally suited to communicating with school-aged children who are often too young to articulate perceptions and feelings spontaneously, but are too old to be engrossed in play techniques utilizing doll houses, puppets, or other toys.

Injuries to children in a Native American community.

The rate of hospitalization of children with injuries in one service unit was three times that of the Albuquerque Area Indian Health Service as a whole. To determine the reasons, mortality and hospitalization data were analyzed and an indepth review of medical records was performed. Among the possible explanations for the high injury rate that were excluded were an artifact of reporting, uncertain denominator data, lack of age-adjustment, lower socioeconomic status of the community, differential thresholds for hospitalization, and an increase in a few specific types of injury. Alternative hypotheses involve life-style issues and psychosocial stress. These hypotheses are supported by data concerning alcohol abuse and foster care and have profound implications for injury control efforts in this community.

Floor furnace burns to children.

Three children with grid-like second-degree burns of their extremities from contact with floor furnace registers prompted an examination of this thermal hazard. Average temperature of the gratings was 294 degrees F (146 degrees C), with a range of 180 degrees to 375 degrees F (82.2 degrees to 191 degrees C). All of the furnaces tested were positioned at the entrance to bedrooms and had so little clearance that it was impossible to walk around them without contact with their surface. Infants and toddlers are at particular risk: 1 or 2 seconds of exposure would be expected to produce a serious burn. Suggestions for preventing burns from floor furnaces include turning them off when young children are at home; installing barrier gates to prevent children from coming in contact with the registers; and developing a surface coating or replacement grate with less hazardous thermal properties.

Naturopaths and childhood immunizations: heterodoxy among the unorthodox.

Many families at a community clinic in Seattle reported that they were choosing not to immunize their children at the advice of practitioners of naturopathy. To learn more about this alternate form of health care, a review of the available literature on naturopathy was undertaken and interviews were conducted with individual naturopaths in the state of Washington. Naturopaths vary widely in their training, practices, and philosophy of healing. Many are opposed to routine immunization because they view immunization programs as unnatural, unnecessary, and elitist. Other practitioners, however, did not actively discourage parents from immunizing their children. Pediatricians must be aware of the growing popularity of naturopathic medicine in their care of families, and in their role as advocates for children.

Injuries from fireworks.

In 1983, there were more than 8,200 victims of fireworks-related injuries treated in US emergency rooms. Half of those injured were children less than 15 years of age, and 11% of the injuries resulted in hospitalization. The eyes are the body part most often injured, followed by hands and fingers. Burns account for the majority of injuries. Every type of fireworks legally available has resulted in serious injury or death. Firecrackers, bottle rockets, and sparklers contribute to the most hospitalizations. States that allow a wide variety of fireworks to be sold for personal use have a rate of fireworks-related fires 50 times greater than states that strictly limit the availability of fireworks. The rate of fireworks-related injuries is more than seven times greater in the less restrictive states.

Promoting the use of car safety devices for infants: an intensive health education approach.

Efforts to promote the use of infant car seats through health education techniques have been disappointing when strict criteria for evaluation are used. Low-income families were targeted and were provided with educational sessions in the prenatal, postdelivery , and infant follow-up periods. Free car seats were given to 179 clients. Base-line and follow-up observations were performed at 4 months after delivery. The proportion of correctly restrained infants increased from 9% to 38%. The number of infants who were lap held decreased from 38% to 18%. The proportion of clients who had an approved car seat but who were using it incorrectly increased from 11% to 23%.

Mouthwash: a source of acute ethanol intoxication.

Treatment of a 33-month-old girl who sustained severe ethanol intoxication resulting from mouthwash ingestion prompted us to review the ingestions, compositions, and sales of these common household products. Mouthwashes contain up to 26.9% ethanol (53.8 proof), and each of the leading brands markets single containers that can supply a lethal ethanol dose to a toddler. Mouthwashes are particularly hazardous because they are thought to be innocuous, and they are widely available, attractive, and kept within easy reach of children. Parent education, and restrictions on packaging and ethanol concentration are recommended.

Increasing breast milk production for premature infants with a relaxation/imagery audiotape.

Many women whose premature infants are hospitalized in a newborn intensive care unit choose to express breast milk for their babies. Yet anxiety, fatigue, and emotional stress are powerful inhibitors of lactation. To facilitate the breast-feeding experience, intervention mothers were given a 20-minute audio cassette tape based on relaxation and visual imagery techniques. At a single follow-up expression of milk at the hospital approximately 1 week after enrollment, they expressed 63% more breast milk than a randomized group of control mothers. The fat content of the breast milk in the two groups was not significantly different. Among a small group of mothers whose infants were receiving mechanical ventilation, the increase in milk volume compared with that of control mothers was 121%. Longer-term effects of the relaxation/imagery approach (such as extending the duration of breast-feeding or reducing parental stress after hospital discharge) and the physiologic basis for the increased volume of expressed milk (improved milk production v more efficient milk ejection) are appropriate topics for future research.

Assessing primary care content: four conditions common in community health center practice.

Under managed care, community health center (CHC) care patterns will be increasingly subject to outside scrutiny. This article discusses results of medical records reviews assessing quality of care at CHCs for acute otitis media, diabetes, asthma, and hypertension. As a group, these safety net providers meet or exceed prevailing practice across other health care settings; however, there is substantial variation among sites. Regression analyses indicate that the individual CHC used by a patient is the most consistent determinant of whether a patient receives recommended care. Drawing on these results, the article explores approaches for improving care and discusses the implications for performance measurement among CHCs and other safety net providers.

Requesting the autopsy: a pediatric perspective. Psychosocial and professional aspects of the autopsy in caring for the dying child and his family.

Many physicians find the request for autopsy to be one of the most difficult and unpleasant aspects of pediatrics. Lack of preparation, their own emotional reactions, and ambivalence about the necessity of autopsies contribute to this. This article offers an approach to the autopsy that emphasizes its importance to families and to pediatrics, and suggests a role for the physician at the time of the child's death that is both professionally and personally gratifying.

The prenatal pediatric visit revisited.

The potential value of prenatal interviews with pediatricians was explored through interviews with 20 low-income women in their last trimester of pregnancy. Major areas of attention included prenatal concerns, psychosocial assessment, and anticipatory guidance. Important issues of relevance to pediatric care emerged, including gaps of parental knowledge, lack of financial and emotional support, and anxieties about the infant. Prenatal pediatric visits also served to encourage the involvement of fathers in pediatric care and to establish an ongoing professional relationship with the pediatrician. In health care settings where comprehensive, coordinated care is often lacking--such as teaching hospitals or county clinics--pediatric providers must take the initiative if families are to be reached prenatally.

Carbon monoxide hazards in rural Alaskan homes.

Alaska has the highest age-adjusted death rate from unintentional carbon monoxide poisoning in the nation. We conducted a study in five villages to determine carbon monoxide levels and sources. Nearly 10% (10/105) of the homes had elevated levels. Improperly vented propane Paloma water heaters were most commonly responsible and produced the highest levels of carbon monoxide. Other sources were leaking pipes from wood stoves and stoves that had been left on for several hours. We recommend that Paloma water heaters not be used where freezing temperatures create a risk for carbon monoxide poisoning, fires, and explosion. Safety education campaigns should note the risks of Paloma water heaters and defective stove pipes, and the need for increased kitchen ventilation during prolonged cooking. Medical workers need to be informed of the prevalence of carbon monoxide exposures. Homeowners can install carbon monoxide detectors, although expense and false alarms remain barriers to their use.

Violence to health care workers in rural Alaska hospitals.

The authors selected five rural Alaska hospitals for a survey of ED workers. The goal was to identify risk factors and preventive strategies to protect workers in these environments.