A method to establish the relationship between chronological age and stage of union from radiographic assessment of epiphyseal fusion at the knee: an Irish population study.

Characteristic changes during epiphyseal union provide a skeletal age, which when compared with age-based standards provides an estimation of chronological age. Currently there are no data on epiphyseal union for the purposes of age estimation specific to an Irish population. This cross-sectional study aims to investigate the relationship between stage of epiphyseal union at the knee joint and chronological age in a modern Irish population. A novel radiographic method that sub-divides the continuum of development into five specific stages of union is presented. Anteroposterior and lateral knee radiographs of 148 males and 86 females, aged 9-19 years, were examined. Fusion was scored as Stage 0, non-union; Stage 1, beginning union; Stage 2, active union; Stage 3, recent union; or Stage 4, complete union. Stage of epiphyseal union is correlated with chronological age in both males and females. Mean age gradually increases with each stage of union and also varies between male and female subjects. A statistically significant difference in mean age was recorded between stages when compared to the previous stage, for the three epiphyses. Irish children are comparable to those from previously published studies with epiphyseal union in females occurring earlier than males. A significant difference was noted between the mean age of union for males and females for each of Stages 1 and 2 for the femur and Stages 0, 1, 2 and 3 for the tibia and the fibula. The results also suggest that the stages of union occur at earlier ages in this Irish population. Implementation of standardized methodology is necessary to investigate if this is due to a secular or population variation in maturation or to a methodology which clearly identifies five stages of union.

Evaluation of a subsidy program to increase bicycle helmet use by children of low-income families.

OBJECTIVE: We have previously shown that an educational program was not effective in increasing bicycle helmet use in children of low-income families. The objective of this study was to evaluate a combined educational and helmet subsidy program in the same population, while controlling for secular trends. The secondary objective was to complete a third year of surveying children's bicycle helmet use throughout the study community. DESIGN: A prospective, controlled, before-and-after study. SUBJECTS: Bicycling children 5 to 14 years of age from areas of low average family income. SETTING: A defined geographic community within a large urban Canadian city. INTERVENTION: In April 1992, students in three schools located in the area of lowest average family income were offered $10 helmets and an educational program; three other low-income areas served as control areas. MAIN OUTCOME MEASURE: Helmet use was determined by direct observation of more than 1800 bicycling children. RESULTS: Nine hundred ten helmets were sold to a school population of 1415 (64%). Reported helmet ownership increased from 10% to 47%. However, observed helmet use in the low-income intervention area was no different from the rate in the three low-income control areas (18% versus 19%). There was no difference in the trend in helmet use during the period of 1990 through 1992 in the intervention area (4% to 18%) compared with the control areas (3% to 19%). Helmet use rates from all income areas have increased from 3.4% in 1990, to 16% in 1991, to 28% in 1992. In 1992, helmet use in the high-income areas was 48% and in the low-income areas was 20%. CONCLUSIONS: There has been a trend toward increasing helmet use in all income areas during the 3-year period. Despite encouraging helmet sales and increases in reported helmet ownership, the results of the observational study do not support the efficacy of a helmet subsidy program in increasing helmet use in children residing in areas of low average family income. Strategies to increase helmet use in children of low average family income remain a priority.

Evaluation of a promotional strategy to increase bicycle helmet use by children.

Bicycle-related head injuries are an important cause of death and disability, despite the availability of helmets. The objective of this study was to evaluate the effectiveness of a school-based bicycle helmet promotion program in increasing helmet use by children while controlling for secular trends. Two high-income and two low-income schools in an urban Canadian community were selected to receive a bicycle helmet promotion intervention, with the remaining 18 schools serving as controls. Approximately 1800 observations of bicycling children were made at randomly selected observational sites 2 to 5 months after the intervention to assess changes in behavior. Helmet use at all observation sites tripled from 3.4% (1990, preintervention) to 16% (1991, postintervention). In the high-income intervention area, observed helmet use rose dramatically from 4% to 36% in contrast to the more modest increase in the high-income control area from 4% to 15%. In the low-income intervention area, there was a modest increase from 1% to 7%, but it did not differ from the increase in the low-income control area from 3% to 13%. The program was highly successful in children of high-income families but not in children of low-income families. Developing strategies for low-income families remains a priority.

Monoclonal antibody characterization of Jamestown Canyon (California serogroup) virus topotypes isolated in Canada.

Jamestown Canyon (JC) virus of the California (CAL) serogroup has been isolated in 12 American states and 6 Canadian provinces. A study was undertaken to produce monoclonal antibodies (MAbs) to JC virus and to use these MAbs to assay for possible heterogeneity among naturally occurring JC topotypes in Canada. MAbs were produced to the prototype strain of JC virus using BALB/c mice. Twenty-seven secreting MAbs were obtained and three of these MAbs were propagated and studied. All three MAbs, M1 (IgG1), M2 (IgG2b), and M3 (IgG2a), were reactive by immunofluorescent antibody assay against JC-infected vero cells and by ELISA against JC antigen. MAb M2 reacted with all members of the Melao complex, MAb M1 reacted only with Keystone virus, while MAb M3 exhibited no reactivity with other CAL serogroup viruses. Only MAb M3 possessed neutralization and hemagglutination inhibition activities against JC virus. The MAbs were also tested by ELISA and for neutralizing activity against 13 JC topotypes isolated in 5 provinces from Newfoundland to Saskatchewan. ELISA confirmed closer identity of the Canadian topotypes to JC as opposed to the closely related South River virus. The MAbs verified all Canadian topotypes to be JC virus but revealed different patterns of reactivity between these topotypes and prototype JC virus.

Immune electron microscopy of arboviruses.

Representative members of four arbovirus taxons were studied by immune electron microscopy (IEM) in an attempt to determine whether the technique can be applied to the specific identification of arboviruses. Alphavirus, flavivirus, bunyavirus, and rhabdovirus antigens were prepared by propagation in tissue culture. The viruses were used to titrate homologous antibody and test heterologous antibody in the IEM test. Specific clumping together with visualization of antibody attachment was observed for all homologous systems studied. For the alphaviruses, titers of antibody, as determined by IEM, were comparable with the titers obtained by hemagglutination inhibition. Alphavirus cross-reactions were observed at low antibody dilutions by IEM. However, further dilution of antibody resulted in specific clumping only of homologous virus, allowing specific identification of alphavirus unknowns. For all viruses studied, positive IEM reactions were obtained with homologous grouping ascitic fluids but not with heterologous grouping fluids.

The relative importance of rotavirus and other pathogens in the etiology of gastroenteritis in Trinidadian children.

Over a 2-year period, 300 infants less than 3 years old with gastroenteritis admitted to hospitals in Trinidad were investigated for the presence of certain microorganisms in the feces, along with an equal number of age- and sex-matched controls. Rotavirus was detected in 23% of cases and 1% of controls; Salmonella in 7% of cases and in 1% of controls; Shigella in 4% of cases and in no controls and two serotypes of enteropathogenic E. coli in 7% of cases and in 2% of controls. Campylobacter fetus subspecies jejuni was cultured from 7 out of 60 cases and from 1 of 60 controls. Enterotoxigenic E. coli, most strains of enteropathogenic E. coli, cytopathic enteroviruses and adenoviruses and fecal parasites were not significantly associated with diarrhea. Rotaviruses were detected throughout the year but were more prevalent in the dry than in the rainy season. They were found less often in children younger than 6 months than in those aged 6 to 35 months and were present in 6 of the 20 children who died.

Antibodies to snowshoe hare virus of the California group in the snowshoe hare (Lepus americanus) population of Nova Scotia.

Serological study showed the presence of antibodies to snowshoe hare virus in 6--14% of snowshoe hares (Lepus americanus) samples in Nova Scotia. This report extends the known range of this virus in North America.

Development of urease conjugated enzyme-linked immunosorbent assays (ELISA) for the detection of IgM and IgG antibodies against Mycoplasma pneumoniae in human sera.

Urease conjugated enzyme linked immunosorbent assays (ELISA) were developed for the detection of human IgM and IgG antibodies against Mycoplasma pneumoniae. Results obtained by ELISA were compared with complement fixation test (CFT); which showed that of the 214 serum specimens tested, 80 were found to have antibody against M. pneumoniae. ELISA revealed that 70 of these specimens were IgG antibody, and 27 of them also contain IgM antibody. CFT failed to detect the presence of antibody against M. pneumoniae in five serum specimens tested. However, by using ELISA, three of them were found to have IgG and IgM antibodies. and the other two sera have IgG antibody only. Four out of the five specimens tested were the first serum specimens collected from patients with clinical and serological evidence of M. pneumoniae infection. In addition, 28 serum specimens, including 10 sera containing IgM rheumatoid factors and sera known to contain IgM antibody to other infectious organisms, were also tested for IgM antibody against M. pneumoniae by ELISA. None of these specimens showed a nonspecific reaction. ELISA had a sensitivity of 87.5% and a specificity of 96.3% when compared with CFT. Thus, ELISA developed in our laboratory is a specific test, and the results indicated that IgM ELISA might be used as a rapid diagnosis for M. pneumoniae infection.

Amplified ELISA for the detection of western equine encephalitis virus from mosquitoes in Manitoba, Canada.

Current monitoring systems to detect western equine encephalitis (WEE) virus in mosquitoes involve isolation in suckling mice or cell culture followed by serological identification of the isolates obtained. Studies were undertaken to develop an amplified ELISA for the rapid detection of WEE virus from mosquitoes. Virus was inoculated onto primary chick embryo cells in 96 well plates, incubated at 37 degrees C for various time periods, monolayers were fixed, and an ELISA performed. By this procedure, 10 plaque-forming units or greater of WEE virus were detected by 24 h postinfection. This amplified ELISA procedure was successfully applied in parallel with standard isolation methods to monitor mosquitoes collected in Manitoba, Canada, in 1985 for WEE virus.

Serological evidence of infection with California serogroup viruses (family Bunyaviridae) in residents of Long Hua, suburb of Shanghai, People's Republic of China.

Sera from 126 residents of Long Hua, a suburb of Shanghai, in the People's Republic of China, were studied. Sera were tested for haemagglutination inhibiting antibodies to alphavirus (eastern equine encephalitis, western equine encephalitis), flavivirus (St. Louis encephalitis, Powassan, dengue) and California serogroup (snowshoe hare) antigens. Flavivirus antibodies were found in 14 (11.1%) and California serogroup antibodies in 5 (3.9%) individuals. Neutralizing antibodies with highest titres to snowshoe hare virus were demonstrated in 3 of the 5 California serogroup reactors. We believe this to be the first report of California serogroup virus antibodies in Chinese residents and the first evidence to suggest that California serogroup viruses may be circulating in the Orient.

Anesthetic complications of tympanotomy tube placement in children.

The anesthetic risks during placement of tympanotomy tubes were prospectively studied in 510 children. Complications were analyzed according to patient risk factors, anesthesia regimen, and surgical variables. No complications were seen in 423 (82.9%) children. Minor degrees of upper airway obstruction (treated with jaw thrust, oral airway, or positive pressure ventilation) were encountered in 61 patients (12.0%), 1 patient had minor obstruction and bradycardia, and 7 patients (1.4%) experienced more severe airway obstruction. Vomiting occurred intraoperatively in 2 patients (0.4%) and postoperatively in 9 patients (1.8%). Twelve patients (2.4%) experienced other complications, including cardiac dysrhythmias, transient hyperthermia, fall from the transport stretcher, and transient agitation. Four patients experienced multiple complications. Patient age, history of anesthesia, and level of experience of the anesthetist were all related to the type and frequency of complications. Anesthesia given for placement of ventilation tubes into tympanic membranes is relatively safe; however, these data are applicable to patients treated by pediatric anesthesiologists in the setting of a children's hospital.

Trends in bicycling-related head injuries in children after implementation of a community-based bike helmet campaign.

BACKGROUND/PURPOSE: The aim of this study was to determine the effect of a community-based bike helmet promotion campaign on bike helmet use and related head injuries in children (0 to 14 years of age) in a large North American city. METHODS: The authors established a multifaceted, multidisciplined, community-based campaign to promote bike helmet use by children in 1989. The goals were to increase helmet use by 100% per year, to reduce fatal bike-related head injuries by 50% overall, and to explore the feasibility of legislation mandating helmet use. Helmet use was measured by standardized field observations repeated annually in a single borough within the metropolitan area. To estimate head injury incidence, the number of admissions to hospital for the treatment of bike-related head injuries in a regional trauma registry, which included all residents in the target population was used. The authors were unable to control for changes in exposure to bicycling or in the criteria for admissions to hospital for the treatment of head injuries during the study period. RESULTS: The bike helmet use rate rose from 4% in 1990 to 67% in 1996. The number of head injury admissions fell from 46 in 1990 to 24 in 1996. Legislation requiring helmet use by all children went into effect in October 1995. CONCLUSIONS: Bike helmet use increased significantly during the first 4 years of the campaign and again after the helmet law was implemented. The total number of bike-related head injury admissions declined by more than 50%. The campaign achieved all of its goals except for a 50% reduction in fatal head injuries, which were too infrequent for analysis.

Fatal bicycle accidents in children: a plea for prevention.

We reviewed the coroner's records of all fatal bicycle accidents occurring in children (aged 0 to 15 years) in Ontario (pediatric population, 2,007,230) between January 1, 1985 and December 31, 1989. The injuries sustained were documented and scored with anatomical injury scores (Abbreviated Injury Score 1985 and Injury Severity Score) and categorized as unsurvivable or survivable. The causes and circumstances were documented from police accident reports. Eighty-one deaths resulted from bicycle accidents, an annual mortality rate of 1.44 deaths per 100,000 children per year. In 74 (91%) of these cases the injuries were deemed unsurvivable, 89% of which were head injuries. Seventy-eight (96%) of the deaths resulted from collisions with motor vehicles. No victim was wearing a helmet at the time of injury. In 70% of the deaths, the cyclist was considered to have caused the collision, either because of a violation of a road traffic law or poor road sense. These findings suggest that more emphasis should be placed on primary and secondary injury prevention by such methods as bicycle safety education for children and the promotion of bike helmet use. In addition, in view of the high incidence of unsurvivable head injury, the introduction of legislation requiring the use of protective helmets should be considered.

Preventable pediatric trauma deaths in a metropolitan region.

All pediatric trauma deaths occurring in metropolitan Toronto (population, 2.2 million) in 1986 were analyzed from the regional coroner's records. Injuries sustained were scored using the Abbreviated Injury Scale (1985; AIS) and Injury Severity Score (ISS). Victims with injuries graded AIS 6 (any region), AIS 5 head/neck (excluding acute epidural hematoma), or ISS greater than 59 were deemed unsalvageable. All other injuries were considered survivable and the deaths from them preventable. Use of these objective criteria indicated that 8/38 of the children (21%) who died from trauma had survivable injuries. Since in three cases medical aid was not sought because of social circumstances, 5/38 (13%) was considered a realistic estimate of preventable death rate (PDR). These results suggest that when objective criteria are used, the PDR in pediatric trauma may be less than that reported in adult trauma victims. Defining the PDR on the basis of objective criteria may prove useful in the conduct of further studies of this kind and permit valid comparisons to be made.

Splenic injury: a 5-year update with improved results and changing criteria for conservative management.

The policy of conservative nonoperative management of the injured spleen is reviewed, and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of thes, ten were operated on (four splenorrhaphies, three total splenectomies, one partial splenectomy; in two, the spleen had stopped bleeding spontaneously) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the ICU was reduced. The results of this review show that, in comparison with our previous 5-year report, the number of patients treated without surgery increased from 70% to 87%, those receiving blood transfusions decreased from 36% to 23%, and the number undergoing a splenectomy decreased from 24% to 4%. These data suggest that almost all children with splenic injury can be successfully treated without an operation, those who are hemodynamically stable do not require ICU care, and the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.

Splenic injury: a 5-year update with improved results and changing criteria for conservative management.

The policy of conservative nonoperative management of injured spleens is reviewed and recommendations are made to improve this mode of therapy. From 1981 to 1986, 75 patients were admitted with diagnosed splenic injury. Of these, ten were operated on (4 splenorrhaphies, 3 total splenectomies, 1 partial splenectomy) and three died, all from causes unrelated to splenic trauma. Only 23% of the patients treated nonoperatively required blood transfusions, and the length of both hospital stay and time spent in the intensive care unit (ICU) was reduced. The results of this review show that, in comparison with our previous 5-year report, (1) the number of patients treated without surgery rose from 70% to 87%, (2) those receiving blood transfusions dropped from 36% to 23%, and (3) the number undergoing a splenectomy fell from 24% to 4%. These data suggest that (1) most children with splenic injury can be successfully treated without operation, (2) those who are hemodynamically stable do not require ICU care, and (3) the total hospital stay for uncomplicated splenic injury can be limited to seven days. A laparotomy can be safely reserved for patients with immediate massive hemorrhage or with transfusion requirements of greater than 40 mL/kg.

Diagnosis and incidence of cardiac injury in children with blunt thoracic trauma.

Over a 20-month period, we prospectively studied 41 children with blunt thoracic trauma (BTT) to determine the incidence and morbidity of cardiac injury in this population. Four patients died, and the data were incomplete in 10, leaving 27 for analysis. Serial electrocardiograms (ECG) were abnormal in 36% of the patients studied, serial creatine phosphokinase isoenzyme (CK-MB) ratios were elevated in 31%, echocardiogram showed septal dysfunction in 14%, and pyrophosphate scan showed grade 1 uptake in 14%. There was poor correlation among tests, since only four patients had more than one abnormal test. There was no significant difference in Injury Severity Score or Thoracic Abbreviated Injury Scale between patients with and without abnormal investigations. No patient in the study developed arrhythmias or cardiac failure. In 13 trauma-related deaths undergoing autopsy over the same period, including the four with thoracic trauma, none had evidence of cardiac injury. These results indicate a striking lack of consistency in the diagnosis of posttraumatic cardiac injury in children using standard investigations. The absence of adverse cardiac events in surviving patients and the lack of autopsy evidence of cardiac injury in the trauma deaths suggest that the actual incidence and clinical significance of these lesions in children is lower than generally reported. Children with BTT should be followed clinically, and reliance on screening tests should be avoided.

Parental attitudes toward legislation for helmet use by child cyclists.

A random-digit dialing telephone survey was conducted in the second half of 1991 to examine parental attitudes toward legislation of helmet use by child cyclists. The surveyed population were 703 parents of at least one child aged 5-17 years who owned a bicycle and lived within Metropolitan Toronto. Five hundred sixty-eight (80.8%) responding parents were in favour of the suggested legislation, 81 (11.5%) were against, and 54 (7.7%) had no opinion on the issue. The 95% confidence interval for the support rate was 78.9-83.7%. Although there was some variation in the level of support, at least two thirds of the respondents in every subgroup, except parents with teenaged children (aged 15-17 years), were in favour of the legislation. Legislation requiring bicycle helmet use by all children has strong support from the public. Additional surveys should be directed at public attitudes to legislation of helmet use by adults.

Current bicycle helmet ownership, use and related factors among school-aged children in metropolitan Toronto.

A random digit dialing telephone survey was conducted to examine bicycle helmet ownership, use and related factors among 707 children in Metropolitan Toronto. The ownership rate was 22% and use rate 12%. Although ownership was similarly distributed by age and sex, helmet use varied considerably across age strata among boys; only about one fifth of teenaged boys who owned a helmet wore it regularly. Both parental education and annual family income were significantly associated with ownership and use. Past bicycle injuries, although increasing helmet ownership, had no positive impact on use. The strength of a parental role model was reflected in the fact that when parents owned and used a helmet, 93% of their children had a helmet and more than 80% of them always wore it. Since about half of parents are cyclists themselves, helmet promotion activities are likely to maximize their effect if they target both parents and children.

Self-induced pneumoparotitis in an adolescent. Report of a case and review of the literature.

Pneumoparotitis is a rare cause of parotid inflammatory disease in both adults and children. A 12-year-old girl is reported who presented with recurrent bilateral parotid swelling. Radiologic evaluation revealed pneumoparotitis associated with masseter muscle hypertrophy. Further investigation revealed the self-induced nature of the condition in this teenager. Self-induced pneumoparotitis has been reported almost exclusively in adolescents who often have psychosocial problems. The clinical presentation, proposed pathophysiology, diagnosis and management of this rare condition are discussed and a review of the literature is presented.