Personalized genomic results: analysis of informational needs.

Use of genomic information in healthcare is increasing; however data on the needs of consumers of genomic information is limited. The Coriell Personalized Medicine Collaborative (CPMC) is a longitudinal study investigating the utility of personalized medicine. Participants receive results reflecting risk of common complex conditions and drug-gene pairs deemed actionable by an external review board. To explore the needs of individuals receiving genomic information we reviewed all genetic counseling sessions with CPMC participants. A retrospective qualitative review of notes from 157 genetic counseling inquiries was conducted. Notes were coded for salient themes. Five primary themes; "understanding risk", "basic genetics", "complex disease genetics", "what do I do now?" and "other" were identified. Further review revealed that participants had difficulty with basic genetic concepts, confused relative and absolute risks, and attributed too high a risk burden to individual single nucleotide polymorphisms (SNPs). Despite these hurdles, counseled participants recognized that behavior changes could potentially mitigate risk and there were few comments alluding to an overly deterministic or fatalistic interpretation of results. Participants appeared to recognize the multifactorial nature of the diseases for which results were provided; however education to understand the complexities of genomic risk information was often needed.

Safety belt laws and disparities in safety belt use among US high-school drivers.

OBJECTIVES: We compared reported safety belt use, for both drivers and passengers, among teenagers with learner's permits, provisional licenses, and unrestricted licenses in states with primary or secondary enforcement of safety belt laws. METHODS: Our data source was the 2006 National Young Driver Survey, which included a national representative sample of 3126 high-school drivers. We used multivariate, log-linear regression analyses to assess associations between safety belt laws and belt use. RESULTS: Teenaged drivers were 12% less likely to wear a safety belt as drivers and 15% less likely to wear one as passengers in states with a secondary safety belt law than in states with a primary law. The apparent reduction in belt use among teenagers as they progressed from learner to unrestricted license holder occurred in only secondary enforcement states. Groups reporting particularly low use included African American drivers, rural residents, academically challenged students, and those driving pickup trucks. CONCLUSIONS: The results provided further evidence for enactment of primary enforcement provisions in safety belt laws because primary laws are associated with higher safety belt use rates and lower crash-related injuries and mortality.

A pilot randomized controlled trial assessing secondary prevention of traumatic stress integrated into pediatric trauma care.

Medical settings provide opportunities for secondary prevention of traumatic stress and other sequelae of pediatric injury. This pilot randomized trial evaluated the delivery and effectiveness of a targeted preventive intervention based on best practice recommendations and integrated within acute medical care. Hospitalized injured children were screened for risk of developing posttraumatic stress disorder (PTSD). Those at risk (N = 85) were randomized to the intervention (n = 46) or usual care (n = 39). The preventive intervention did not reduce PTSD or depression severity or increase health-related quality of life, compared to usual care. Both groups improved over time, but 6 months postinjury approximately 10% of each group still met criteria for PTSD, suggesting room for improvement in comprehensive pediatric injury care.

Poor post-operative growth in infants with two-ventricle physiology.

BACKGROUND: Adequate nutritional support is essential for normal infant growth and development. Infants with congenital cardiac disease are known to be at risk for growth failure. We sought to describe perioperative growth in infants undergoing surgical repair of two-ventricle congenital cardiac disease and assess for predictors of their pattern of growth.Materials and methodsFull-term infants who underwent surgical repair of two-ventricle congenital cardiac disease at a single institution were enrolled in a retrospective cohort study performed following a larger prospective study. Infants with facial, gastrointestinal, or neurologic anomalies, trisomy chromosomal abnormality, birth weight less than 2500 grams, or those transferred to another institution before discharge home were excluded. The primary outcome was change in weight-for-age z score from surgery to discharge. Our secondary outcome variable was post-operative hospital length of stay. RESULTS: A total of 76 infants met the inclusion criteria. Medain age at surgery was 5 days with a range from 1 to 44. The median weight-for-age z score at surgery was -0.2 with a range from -2.9 to 2.8 and by discharge had dropped to -1.2 with a range from -3.4 to 1.8. The median change in weight-for-age z score from surgery to discharge was -1.0 with a range from -2.3 to 0.2. Delayed post-operative nutrition (p < 0.001) and reintubation following initial post-operative extubation (p = 0.001) were associated with decrease in weight-for-age z score. CONCLUSIONS: Infants undergoing repair of two-ventricle congenital cardiac disease had poor growth in the post-operative period. This may be mitigated by early initiation of post-operative nutrition.

Weight change in infants with a functionally univentricular heart: from surgical intervention to hospital discharge.

OBJECTIVE: The purpose of this study was to assess the pattern of weight change from surgical intervention to home discharge and to determine predictors of poor growth in this population of infants with congenital cardiac disease. METHODS: Neonates with functionally univentricular physiology enrolled in a prospective cohort study examining growth between March, 2003 and May, 2007 were included. Weights were collected at birth, before surgical intervention, and at hospital discharge. In addition, retrospective echocardiographic data and data about post-operative complications were reviewed. Primary outcome variables were weight-for-age z-score at discharge and change in weight-for-age z-score between surgery and discharge. RESULTS: A total of 61 infants met the inclusion criteria. The mean change in weight-for-age z-score between surgery and hospital discharge was minus 1.5 plus or minus 0.8. Bivariate analysis revealed a significant difference in weight-for-age z-score between infants who were discharged on oral feeds, minus 1.1 plus or minus 0.8 compared to infants with feeding device support minus 1.7 plus or minus 0.7, p-value equal to 0.01. Lower weight-for-age z-score at birth, presence of moderate or greater atrioventricular valve regurgitation, post-operative ventilation time, and placement of an additional central venous line were associated with 60% of the variance in weight-for-age z-score change. CONCLUSION: Neonates undergoing staged surgical repair for univentricular physiology are at significant risk for growth failure between surgery and hospital discharge. Haemodynamically significant atrioventricular valve regurgitation and a complex post-operative course were risk factors for poor post-operative weight gain. Feeding device support appears to be insufficient to ensure adequate weight gain during post-operative hospitalisation.

Sustainability of an in-home fire prevention intervention.

Residential fires remain a challenge in many parts of the United States. This project assessed the sustainability of a community-based fire prevention intervention on household fire safety knowledge and practices. The design was a prospective, cohort study including preintervention and postintervention surveys, which assessed participants' fire safety knowledge and behavior. The implementation of an in-home visit to educate parents of third- and fourth-grade students on escape planning coupled with the installation of smoke alarms can be successful in increasing basic fire safety knowledge and household fire safety practices.

Psychometric Properties of Two Developmental Screening Instruments for Hispanic Children in the Philadelphia Region.

OBJECTIVE: To assess the validity of Spanish versions of the Survey of Well-being of Young Children (SWYC) Milestones and the Ages & Stages Questionnaire, Third Edition (ASQ-3), and to document the rates of developmental delays in an urban cohort of children with Hispanic parents. METHODS: Spanish-speaking families with a child 9 to 60 months of age (N = 991) were initially screened using Spanish translations of the SWYC Milestones and the ASQ-3. A stratified random sample of 494 of these children subsequently received standardized clinical assessment to confirm the presence of developmental delays. Reverse weighting corrected for the selection bias inherent in the stratification scheme. RESULTS: Fifty-five percent of toddlers (9 to 41 months of age) and 34.8% of preschoolers (42 to 60 months of age) scored in the moderately to severely delayed range, most frequently in language. Sensitivity and specificity for toddlers with severe delays associated with the SWYC were 0.69 and 0.64, respectively, and 0.55 and 0.75 for the ASQ-3. Sensitivity and specificity for preschoolers with severe delays associated with the SWYC were 0.87 and 0.58, respectively, and 0.71 and 0.86 for the ASQ-3. CONCLUSIONS: Although psychometric properties of the Spanish translated versions are not as strong as the English versions, the findings suggest that both the SWYC Milestones and ASQ-3 represent promising tools for identifying Hispanic children with developmental delays. The rate of delays were consistent with other studies showing a high percentage of Hispanic children with developmental delays, most frequently in language skills.

Effect of Primary Care Parent-Targeted Interventions on Parent-Adolescent Communication About Sexual Behavior and Alcohol Use: A Randomized Clinical Trial.

Importance: Adolescent well care visits provide opportunities for clinicians to facilitate parent-adolescent communication (PAC) to reduce pregnancy, sexually transmitted infections, and alcohol-related harm among adolescents. Objective: To test the effect of brief parent-targeted interventions delivered in primary care settings on PAC about sexual and alcohol use behaviors. Design, Setting, and Participants: Randomized clinical trial conducted at a primary care pediatric practice from January 4, 2016, to April 10, 2017. Adolescents who were scheduled for a well care visit were recruited, along with their parent or guardian. Data analyses continued through April 30, 2018. Interventions: During well care visits, parents in sexual health intervention and alcohol prevention intervention groups received coaching to discuss written intervention materials encouraging PAC about sex or alcohol, respectively, with their adolescent within 2 weeks, followed by a brief clinician endorsement. After 2 weeks, parents received a follow-up telephone call. Control group parents received usual care. Main Outcomes and Measures: Participants were surveyed 4 months after the well care visit. Parent-reported and adolescent-reported quality of PAC was measured using the 20-item Parent-Adolescent Communication Scale, in which a higher score indicates better PAC; and frequency of PAC about sex or alcohol was measured using a 4-point Likert-type scale with 1 indicating not at all or never, and 4 indicating a lot or often. Results: Of 196 parent-adolescent dyads assessed for eligibility, 118 (60.2%) were eligible to participate. These 118 dyads were randomized to 1 of 3 groups: (1) sexual health intervention (n = 38 [32.2%]); (2) alcohol prevention intervention (n = 40 [33.9%]); and control (n = 40 [33.9%]); 104 parents (88.1%) and 99 adolescents (83.9%) completed the study. Parents included 112 women (94.9%) and had a mean (SD) age of 45.8 (6.9) years. Adolescents included 60 girls (50.9%); 67 adolescents (56.8%) were aged 14 years, and 51 adolescents (43.2%) were aged 15 years. Participant race/ethnicity reflected that of the practice (63 black adolescents [53.4%]; 46 white adolescents [38.9%]; 111 non-Hispanic adolescents [94.1%]). At baseline, 15 adolescents (12.7%) reported a history of sexual behavior and 16 adolescents (13.6%) reported a history of alcohol use. Intention-to-treat analyses found that 4 months after the intervention, adolescents in the sexual health intervention group reported a higher mean frequency score for PAC about sex compared with those in the control group (2.32 [95% CI, 1.97-2.66] vs 1.79 [95% CI, 1.50-2.08]; P = .02); adolescents in the alcohol prevention intervention group reported a higher mean frequency score for PAC about alcohol compared with those in the control group (2.93 [95% CI, 2.60-3.25] vs 2.40 [95% CI, 2.08-2.72]; P = .03). Parent-reported frequency scores for PAC about sex or alcohol did not differ by group. Conclusions and Relevance: Brief parent-targeted interventions in primary care settings increased adolescent-reported frequency of PAC about sexual health and alcohol use and may be an important strategy for parents to influence adolescent behaviors and health outcomes. Trial Registration: ClinicalTrials.gov identifier: NCT02554682.

Intrauterine Device Insertion Procedure Duration in Adolescent and Young Adult Women.

STUDY OBJECTIVE: Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine vs sham paracervical nerve block for pain control during levonorgestrel 13.5 mg IUD insertion. Adolescent and young adult women ages 14-22 years were recruited from 3 outpatient academic sites in Philadelphia, Pennsylvania. INTERVENTIONS AND MAIN OUTCOME MEASURES: Pain scores were recorded at 7 steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. RESULTS: Ninety-five women enrolled. Nineteen (19/95, 20%) were ages 14-17 and 76 (76/95, 80%) were ages 18-22 years. The median procedure duration (seconds ± interquartile range) was longer for adolescents than for young adults (555 ± 428 seconds vs 383 ± 196 seconds; P = .008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (P = .3832). CONCLUSION: The difference in duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women on the basis of age alone.

Serum linoleic acid status as a clinical indicator of essential fatty acid status in children with cystic fibrosis.

BACKGROUND: Children with cystic fibrosis (CF) and pancreatic insufficiency (PI) are at increased risk for essential fatty acid (EFA) deficiency. OBJECTIVES: To investigate serum markers of EFA status in children with CF and PI and their association with growth, body composition, and lung function. PATIENTS AND METHODS: Serum phospholipid fatty acid, growth, and forced expiratory volume at 1 second (FEV1, percentage predicted) status were assessed at baseline and 12 months in 77 children with CF and PI, 7 to 10 years old. Longitudinal mixed-effects models were used to compare associations of the triene:tetraene ratio (ratio of eicosatrienoic acid to arachidonic acid) and serum linoleic acid (as a molar percentage of total serum phospholipid fatty acids, or mol%) with the clinical outcomes. Controls for serum fatty acid were 23 healthy white age- and sex-matched children. RESULTS: Children with CF and PI had higher median triene:tetraene ratio and lower linoleic acid than healthy controls. Depending on the triene:tetraene ratio cutoff point used (0.04 or 0.02), either 17% or 52% of the children with CF had EFA deficiency, respectively. Only linoleic acid was significantly and positively associated with z scores for weight, height, body mass index, upper arm muscle area, and FEV1 at baseline. Children with linoleic acid at 21 mol% or higher had significantly better growth and pulmonary status than those with lower concentrations. CONCLUSIONS: Serum phospholipid linoleic acid at 21 mol% or higher was associated with better growth, body composition, and FEV1. No clinical outcome associations were found with the triene:tetraene ratio. These findings suggest that linoleic acid concentration was a more clinically relevant biomarker of EFA status than the triene:tetraene ratio in children with CF and PI. Further research is warranted to validate this specific percentage of linoleic acid cutoff point as a new recommendation for clinical use.

Adolescents Spending Time Alone With Pediatricians During Routine Visits: Perspectives of Parents in a Primary Care Clinic.

PURPOSE: To increase understanding of parental perspectives on time alone and of factors that influence adolescent communication with physicians in a pediatric clinic. METHODS: The sample consisted of 91 parents of adolescents aged 14-17 years who attended a well child visit at one primary care pediatric practice and completed a 2-week follow-up phone call as part of a larger study on adolescent health and communication. Parents reported whether their child met alone with the pediatrician, rated the importance of him or her having time alone with the physician, and responded to open-ended questions regarding barriers and facilitators of adolescent-physician communication. Bivariate and multivariate analyses tested associations of parent and adolescent characteristics with perceived parental importance of time alone. We conducted content analyses of responses to open-ended questions. RESULTS: Slightly more than half of parents (n = 53, 58%) indicated that it was "a lot" important for their adolescents to meet alone with the pediatrician; parents of males were more likely than parents of females to select this highest rating (73% vs. 43%, χ2(1) = 8.34, p = .004; adjusted odds ratio 4.88, 95% confidence interval 1.84-12.96). Responses to open-ended questions identified numerous adolescent, parent, and provider factors that parents perceived to influence adolescent-physician communication during well child visits, such as preparation for visit, rapport and familiarity with the pediatrician, privacy concerns, time alone with the pediatrician, emotional comfort, trust, and support. CONCLUSIONS: Most parents thought time alone was highly important for their own adolescent in a primary care setting, and parents described additional strategies to facilitate adolescent communication.

Satisfaction With the Intrauterine Device Insertion Procedure Among Adolescent and Young Adult Women.

OBJECTIVE: To evaluate satisfaction with intrauterine device (IUD) insertion procedures among adolescent and young adult women. METHODS: This secondary analysis of data from a multisite, single-blind, sham-controlled randomized trial of women having a levonorgestrel 13.5-mg IUD inserted enrolled participants from March 2015 through July 2016 at three family planning clinics in Philadelphia, Pennsylvania. Eligible participants were 14-22 years of age, nulliparous, not pregnant, and English-speaking. Randomization was computer-generated allocation in block sizes of four to a 1% lidocaine paracervical or sham block. Only patients were blinded. Satisfaction was measured with three items that assessed overall satisfaction with the procedure, whether participants would recommend the IUD to a friend, and the perception that the IUD was worth the discomfort. Predictors included demographics, sexual and reproductive history, pain after IUD insertion, and treatment group. RESULTS: Ninety-five women enrolled; 93 (97.9%) were included in the analysis. Forty-five (47.4%) were white, 34 (36.0%) were black, 62 (66.0%) were privately insured, and 75 (79.0%) had used contraception previously. Most (n=73 [76.8%]) reported high overall satisfaction with the procedure, 64 (67.4%) would recommend an IUD to a friend, and 79 (83.2%) perceived the IUD was worth the discomfort. The odds of reporting high overall satisfaction were lower among adolescents compared with young adults (odds ratio [OR] 0.07, 95% CI 0.008-0.68); those who never had a gynecologic examination compared with those who had (OR 0.26, 95% CI 0.07-0.99); and decreased as pain score increased (OR 0.96, 95% CI 0.94-0.99). Higher pain scores were negatively correlated with the odds of recommending an IUD to a friend and perceiving the IUD was worth the discomfort. CONCLUSION: Adolescent and young adult women report high levels of satisfaction after the IUD insertion procedure. Young age, lack of experience with gynecologic examinations, and high pain were inversely related to satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02352714.

Reducing Pain During Intrauterine Device Insertion: A Randomized Controlled Trial in Adolescents and Young Women.

OBJECTIVE: To estimate the effect of a 1% lidocaine paracervical nerve block on pain during intrauterine device (IUD) insertion compared with a sham block in adolescents and young women. METHODS: We conducted a multisite, single-blind, sham-controlled randomized trial in adolescents and young women having a 13.5-mg levonorgestrel IUD inserted. Enrollment occurred at three family planning clinics in Philadelphia, Pennsylvania. Eligible adolescents and young women were aged 14-22 years, nulliparous, not currently or recently pregnant, and English-speaking. Participants were randomized using computer-generated allocation in block sizes of four to receive a 10-mL 1% lidocaine paracervical block or a sham block (1 cm depression of the vaginal epithelium at paracervical block sites with a wooden cotton-tipped applicator). Only patients were blinded. The primary outcome was pain after IUD insertion measured with a 100-mm visual analog scale. Using a two-sided t test and assuming a 20-mm difference in visual analog scale scores, a SD of 28 mm, an α of 0.05, and 90% power, a sample of 43 participants per group was estimated. RESULTS: Between March 2015 and July 2016, 95 participants enrolled (47 lidocaine block group; 48 sham block group). All were included in the analysis. Forty-four percent were white, 36% black, 65% privately insured, and 79% previously used contraception. The median visual analog scale score after IUD insertion was 30.0 (95% CI 20.0-58.0) in the lidocaine block group and 71.5 (95% CI 66.0-82.0) in the sham block (P<.001). CONCLUSION: A 10-mL 1% lidocaine paracervical nerve block reduces pain during IUD insertion in adolescents and young women compared with a sham block with pressure on the vaginal epithelium. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02352714.

Parent-child agreement regarding children's acute stress: the role of parent acute stress reactions.

OBJECTIVE: We examined parent-child agreement regarding child acute stress disorder (ASD) and the relationship between parent ASD symptoms and parent ratings of child ASD. METHOD: Parent-child dyads (N = 219; child age 8-17 years) were assessed within 1 month of child injury. Parent-child agreement was examined regarding child ASD presence, severity, and specific symptoms. Relationships among parent ASD and parent- and child-reported child ASD were examined using regression analysis and generalized estimating equations (GEE). RESULTS: Parent-child agreement was low for presence of child ASD (kappa = 0.22) and for individual symptoms. Parent and child ratings of child ASD severity were moderately correlated (r = 0.35). Parent ASD was independently associated with parent-rated child ASD, after accounting for child self-rating (beta =.65). Generalized estimating equations indicated that parents with ASD overestimated child ASD and parents without ASD underestimated child ASD, compared to the child's self-rating. CONCLUSIONS: Parents' own responses to a potentially traumatic event appear to influence their assessment of child symptoms. Clinicians should obtain child self-report of ASD whenever possible and take parent symptoms into account when interpreting parent reports. Helping parents to assess a child's needs following a potentially traumatic event may be a relevant target for clinical attention.

Heart rate and posttraumatic stress in injured children.

BACKGROUND: Elevated, acute heart rate has been related to later posttraumatic stress disorder (PTSD) development in injured adults, but this has not been examined in children and adolescents. Better understanding of the relationship between acute physiological arousal and later child PTSD could help elucidate the etiology of posttrauma responses in children and might identify useful markers for PTSD risk. OBJECTIVE: To evaluate the relationship between heart rate assessed in the emergency department (ED) during normal clinical care and later PTSD outcome in traumatically injured children. DESIGN: Prospective cohort study assessed heart rate at ED triage and PTSD an average of 6 months' postinjury. SETTING: Large, urban pediatric academic medical center in the northeastern United States. PARTICIPANTS: One hundred ninety children and adolescents (aged 8-17 years) hospitalized for traffic-related injury.Main Outcome Measure Clinician-Administered PTSD Scale for Children and Adolescents. RESULTS: The group of children who developed partial or full PTSD had a higher mean +/- SD heart rate at ED triage than those who did not go on to have PTSD (109.6 +/- 22.3 vs 99.7 +/- 18.0 beats per minute). Children with an elevated heart rate (defined as >/=2 SDs higher than the normal resting heart rate for their age and sex) at ED triage were more likely to meet criteria for partial or full PTSD at follow-up, even after adjusting for age, sex, and injury (adjusted odds ratio, 2.4 [95% confidence interval, 1.1-5.4]). CONCLUSION: These results suggest an association between early physiological arousal and the development or persistence of PTSD symptoms in injured children and point to the importance of better understanding the interplay between physiological and psychological functioning after a traumatic stressor.

Evaluating predictive screening for children's post-injury mental health: New data and a replication.

BACKGROUND: Recommended approaches for secondary prevention of posttrauma mental health difficulties in children require empirically sound predictive screening to determine which children require more intensive monitoring or targeted intervention. Although there are several promising screening tools for injured children, none has emerged as the gold standard, and little replication data are available regarding their performance. OBJECTIVE: To evaluate a predictive screening protocol for risk of later posttraumatic stress (PTS) and depression outcomes and address a crucial lack of replication studies by examining performance of two previously published screening tools (Screening Tool for Early Predictors of PTSD [STEPP] and Child Trauma Screening Questionnaire [CTSQ]). METHOD: The study enrolled 290 children hospitalized after acute injury. A three-part screening protocol, including acute PTS and depression symptoms and other empirically derived risk factors, was administered in hospital as part of a stepped care study. PTS and depression symptoms and health-related quality of life (HRQoL) were assessed 6 months post-injury.

Design and implementation of a randomized controlled trial of genomic counseling for patients with chronic disease.

We describe the development and implementation of a randomized controlled trial to investigate the impact of genomic counseling on a cohort of patients with heart failure (HF) or hypertension (HTN), managed at a large academic medical center, the Ohio State University Wexner Medical Center (OSUWMC). Our study is built upon the existing Coriell Personalized Medicine Collaborative (CPMC®). OSUWMC patient participants with chronic disease (CD) receive eight actionable complex disease and one pharmacogenomic test report through the CPMC® web portal. Participants are randomized to either the in-person post-test genomic counseling-active arm, versus web-based only return of results-control arm. Study-specific surveys measure: (1) change in risk perception; (2) knowledge retention; (3) perceived personal control; (4) health behavior change; and, for the active arm (5), overall satisfaction with genomic counseling. This ongoing partnership has spurred creation of both infrastructure and procedures necessary for the implementation of genomics and genomic counseling in clinical care and clinical research. This included creation of a comprehensive informed consent document and processes for prospective return of actionable results for multiple complex diseases and pharmacogenomics (PGx) through a web portal, and integration of genomic data files and clinical decision support into an EPIC-based electronic medical record. We present this partnership, the infrastructure, genomic counseling approach, and the challenges that arose in the design and conduct of this ongoing trial to inform subsequent collaborative efforts and best genomic counseling practices.

Boosting restraint norms: a community-delivered campaign to promote booster seat use.

OBJECTIVE: The objective of this study was to evaluate the effectiveness of a theoretically grounded community-delivered marketing campaign to promote belt-positioning booster seat (BPB) use among vulnerable populations when disseminated by community members. METHODS: A prospective, nonrandomized community intervention trial was conducted to evaluate the "Boosting Restraint Norms" social marketing campaign delivered by community partners in Norristown, Pennsylvania (intervention community), between October 2008 and November 2008. York, Pennsylvania, served as the comparison community. In total, 800 vehicles with 822 children aged 4 to 7 years were observed for BPB use, the primary outcome of interest, at baseline (September 2008) and at 6 months after intervention (April 2009). RESULTS: During the study period, a 28 percent increase in the prevalence of BPB use at 6 months was observed in the intervention community with no change in the prevalence of BPB use in the comparison community. After adjustment for child age and gender, vehicle type, driver gender, and driver level, BPB use increased from 39 to 50 percent in the intervention community. CONCLUSIONS: The "Boosting Restraint Norms" social marketing campaign, distributed through community organizations combined with caregiver education and a one-time free distribution of BPBs, was effective in increasing BPB use. This study demonstrates the feasibility of utilizing community organizations with established audiences to spread the "No Regrets" messaging of the campaign in the community. This study also indicates that spreading evidence-based messages in this manner may effectively change behavior in populations that are often hard to reach. Future studies are needed in which this methodology is tested in additional communities and rural settings.

An assessment of clinical performance measures for pediatric emergency physicians.

The objectives were to evaluate clinical performance measures used for pediatric emergency medicine (PEM) physicians for reliability, correlation with one another, and relationship with clinical experience. This retrospective cohort study collected performance data for PEM physicians working at an urban children's hospital emergency department (ED) for each of 7 consecutive 6-month periods. Low correlations were seen between patients per hour or admission rate and 72-hour revisit rates. No significant association existed between level of experience and any performance measure. Physician treatment times appeared to be most reliable, and revisit rates were least reliable. Increase in number of patients seen per hour or lower admission rates in the ED are not significantly associated with an increase in revisit rates. Provider experience did not affect performance measures. Physician treatment time, patients per hour, admission rate, and charges per hour are reliable measures to assess the clinical performance of PEM physicians working at a single center.

Comparative Performance of Rear Facing Child Restraint Systems on the CMVSS 213 Bench and Vehicle Seats.

The purpose of this study was to compare the dynamic response of rear-facing child restraint systems (RFCRS) installed on the CMVSS 213 sled bench and a selection of vehicle seats. Thirty-six sled tests were conducted: three models of rear facing CRS with an anthropomorphic test device (ATD) representing a 12 month old child (CRABI) were affixed via lower anchors (LATCH), 3 point belt without CRS base, and 3 point belt with CRS base to one of three vehicle seats or the CMVSS 213 bench seat. All CRS were subjected to an identical sled acceleration pulse. Two types of matched pair analysis: "bench-to-vehicle" and "method of attachment" were conducted. Statistically significant differences were observed in the kinematic responses of the ATD and the CRS.This is the first study to quantify differences between the regulatory bench and vehicle seats on a system level and evaluate the influence of attachment method. Our results show that the difference in RFCRS forward excursion between 3-point belt with base and LATCH installations was between 1 and 7 percent on the bench and 22 to 76 percent on the vehicle seats. When evaluating the dynamic performance of RFCRS, the use of real vehicle seats from vehicles that commonly carry children may provide valuable insight. The findings would require further confirmation using a broader selection of RFCRS and vehicle seats, before generalizable conclusions can be drawn.