Interventions for promoting booster seat use in four to eight year olds traveling in motor vehicles.

BACKGROUND: Public health and traffic safety agencies recommend use of booster seats in motor vehicles for children aged four to eight years, and various interventions have been implemented to increase their use by individuals who transport children in motor vehicles. There is little evidence regarding the effectiveness of these interventions, hence the need to examine what works and what does not. OBJECTIVES: To assess the effectiveness of interventions intended to increase acquisition and use of booster seats in motor vehicles among four to eight year olds. SEARCH STRATEGY: We searched the Cochrane Injuries Group's Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE (January 1966 to April 2005), EMBASE (1980 to April 2005), LILACS, Transport Research Databases (1988 to April 2005), Australian Transport Index (1976 to April 2005), additional databases and reference lists of relevant articles. We also contacted experts in the field. SELECTION CRITERIA: We included randomized and controlled before-and-after trials that investigated the effects of interventions to promote booster seat use. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: Five studies involving 3,070 individuals met the criteria for inclusion in the meta-analysis. All interventions for promoting use of booster seats among 4 to 8 year olds demonstrated a positive effect (relative risk (RR) 1.43; 95% confidence intervals (CI) 1.05 to 1.96). Incentives combined with education demonstrated a beneficial effect (RR 1.32, 95% CI 1.12 to 1.55; n = 1,898). Distribution of free booster seats combined with education also had a beneficial effect (RR 2.34; 95% CI 1.50 to 3.63; n = 380) as did education-only interventions (RR 1.32; 95% CI 1.16 to 1.49; n = 563). One study which evaluated enforcement of booster seat law met the criteria for inclusion in the meta-analysis, but demonstrated no marked beneficial effect. AUTHORS' CONCLUSIONS: Available evidence suggests that interventions to increase use of booster seats among children age four to eight years are effective. Combining incentives (booster seat discount coupons or gift certificates) or distribution of free booster seats with education demonstrated marked beneficial outcomes for acquisition and use of booster seats for four to eight year olds. There is some evidence of beneficial effect of legislation on acquisition and use of booster seats but this was mainly from uncontrolled before-and-after studies, which did not meet the criteria for inclusion in the meta-analysis.

Pediatric trauma: impact on work and family finances.

OBJECTIVES: National data now exist on incidence, prevalence, and cost of injury. However, the personal impact of injury on work and family finances has not been thoroughly studied. We examine the extent and nature of work and financial problems after pediatric trauma and identify predictors. Clinicians are alerted so they can better counsel parents about potential postinjury work and financial difficulties. METHODS: Staff collected comprehensive data on the acute care and short-term rehabilitation of 182 Massachusetts children with injuries. Consenting parents were surveyed and their children were given a battery of medical, functional, and psychosocial tests. Information on work and financial impact at 1 and 6 months postinjury was available from 120 parents. RESULTS: Given these children's generally mild injuries, the impact on work and family finances was remarkable. For many families work and financial problems were short-lived; however, for others serious problems remained at 6 months postdischarge. Families whose children were severely injured were at highest risk for work and financial problems. Middle-class parents and parents on public assistance or in our other insurance category reported more work and financial problems than those in health maintenance organizations. Long acute hospital stay and four or more impairments at discharge were also strong predictors. CONCLUSION: Childhood injury can lead to serious work and financial problems for families. Given the central role of the family in pediatric rehabilitation, clinicians and policymakers involved in acute trauma care and rehabilitation should pay greater attention to the financial repercussions of injury.

Skateboarding: more dangerous than roller skating or in-line skating.

OBJECTIVE: To describe the circumstances, severity, and outcomes of skating-related injuries among children admitted to trauma centers. DESIGN: A cross-sectional comparison of roller skaters (n = 154), in-line skaters (n = 190), and skateboarders (n = 254) aged 5 to 19 years who were hospitalized with injuries. SETTING: Seventy-nine hospitals and pediatric trauma centers participating in the National Pediatric Trauma Registry between October 1988 and April 1997. RESULTS: Three quarters (75.8%) of the study sample were male, nearly half (47.8%) were injured on roads, and more than one third (37.1%) had head injuries. Among skateboarders, 50.8% had head injuries compared with 33.7% of in-line skaters and 18.8% of roller skaters (P<.001). According to the Injury Severity Score, injuries to skateboarders were 8 times more likely to be severe or critical compared with roller skaters' injuries and more than 2 times as likely to be severe or critical compared with in-line skaters' injuries. Mean hospital length of stay was 6.0 days for skateboarders, 3.4 days for in-line skaters, and 2.4 days for roller skaters (P<.001). Skateboarders were more likely to be male and to be injured on roads than were in-line skaters or roller skaters. CONCLUSIONS: Skateboarding-related injuries are more severe and have more serious consequences than roller skating or in-line skating injuries. Research is needed to identify ergonomic and behavioral factors responsible for higher head injury risk to skateboarders, and interventions are needed to reduce the risk.

Social supports as a determinant of community-based care utilization among rehabilitation patients.

OBJECTIVE: We determine the extent to which noninstitutionalized long-term care patients receive assistance from family members and friends, and evaluate the effect of this assistance on use of outpatient rehabilitative and personal care services. DATA SOURCES AND STUDY SETTING: Over 12 months, primary data were collected from 289 patients in noninstitutional settings after inpatient rehabilitation at three Boston-area rehabilitation hospitals. Data on patients' acute and rehabilitative stays were obtained from medical record reviews. Patients provided primary data on sociodemographics, living arrangements, social supports, functional status, health behaviors, life events, and use of outpatient services during the study period. The latter was verified and service charge data obtained from the care providers. STUDY DESIGN: The study was longitudinal and observational. Patient-provided information was obtained at one, six, and twelve months postdischarge. ANALYTIC METHODS: Multivariate Tobit regression was used to evaluate the effect of social supports on patients' use of rehabilitative and personal care services, controlling for sociodemographics and functional status. Service use was measured as charges incurred during the 12-month study period. PRINCIPAL FINDINGS: Results confirm the primary role of family and friends in providing daily personal care and identify the availability of that support as a key determinant of expenditures on community-based personal care services. Social supports do not predict outpatient rehabilitative service use. CONCLUSIONS: Differing eligibility criteria seem appropriate for outpatient rehabilitative and personal care services. The current emphasis on functional status in determining rehabilitative service eligibility appears appropriate; but we find that considering patients' social supports would be both meaningful and appropriate in determining personal care service eligibility. This approach would avert the expense of making personal care services universally available, while facilitating assistance for patients whose functional and social status put them at increased risk of institutional placement.

Total charges for inpatient medical rehabilitation.

Descriptive information on inpatient charges for a sample of 151 individuals discharged from three Boston area medical rehabilitation facilities is presented in this article. The total charges for inpatient rehabilitation were nearly $3 million, and the mean charge was $19,568. Also presented are a description of how charges vary by medical, demographic, social, and external factors and an identification of predictors of total charges for inpatient medical rehabilitation. These results establish a reference point for developing prospective payment systems for inpatient medical rehabilitation.

Kappa coefficient calculation using multiple ratings per subject: a special communication.

The purpose of this special communication is to describe the application of the Kappa coefficient for the estimation of interobserver agreement. Kappa is a preferred statistic for the estimation of the accuracy of nominal and ordinal data in clinical research by physical therapists. A brief introduction to the properties of the Kappa coefficient is given, and a special case of Kappa for multiple ratings per subject is explained. A FORTRAN program, written specifically for the multiple-ratings situation, is described.

Bicycle safety behavior in Paris and Boston.

Concerns about bicycle-related deaths and injuries have led to extensive injury prevention efforts in the United States, yet these concerns are not universal. For instance, in France attitudes toward bicycle safety are quite different. To understand more about variation in urban bicycle safety behavior, we observed passing bicyclists in Paris and Boston. In addition to helmet use, we looked at use of lights at night. Among 5,808 passing bicyclists, there were large differences in helmet and light use: only 2.2% of Paris bicyclists wore helmets compared to 31.5% in Boston. In contrast, 46.8% of nighttime Paris bicyclists had working head or tail lights compared to only 14.8% in Boston. These large and seemingly contradictory percentages are the result of different laws and public health priorities, types of bicycle riding, and perceived risks. Suggestions for further research and practical ways to improve U.S. bicycle safety behavior are discussed.

Information needs on childhood TBI: survey results of experts.

Until recently, information about childhood brain injury was rarely geared toward families or educators. Yet information is critical, according to our survey of 89 experts. We asked about the type of information needed, groups needing information, and issues of timing. Respondents were most concerned about brain injury information gaps for parents, educators, and community physicians. Basic information about brain injury among children, methods of coping, and advocacy strategies were deemed most important. Good multi-media materials are needed, so people can quickly learn the basics, find where to learn more, and make contacts in the brain injury community. New Internet discussion groups, mailing lists, and websites appear almost daily. As more user-friendly information on brain injury gets placed on the Internet, more needs to be done to make this information accessible to all citizens.

Aging and health: a longitudinal study.

A set of double jeopardy hypotheses predicting there is a double health disadvantage in growing old and being a member of an ethnic minority, female, of lower socioeconomic status, and unmarried is tested with data from a 4-yr longitudinal study of older Mexican Americans and Anglos. With the exception of socioeconomic status, little support is found for the double jeopardy predictions in a multivariate analysis of change in health. When subjects who died during the study interval were included in the analysis by assigning them the lowest score on health, the results changed somewhat: the relationship between age and decline in health was strengthened and the effect of sex changed from a direction suggesting that women show greater declines in health with age to a direction suggesting that men experience greater declines in health with age. Implications of the effect of decreased dropouts for studies on aging and health are discussed.

Differences in follow-up visits between African American and white Medicaid children hospitalized with asthma.

Asthma-related hospitalizations and mortality have risen at alarming rates in the past two decades, taking a disproportionate toll on African American children. Adverse asthma outcomes have been attributed to inadequacies in primary care, raising concerns about the quality of primary care delivered to African American children. To assess differences in care between African American and white children, the authors identified 500 children enrolled in Massachusetts Medicaid and hospitalized for asthma, and reviewed their medical claims data for the six-month period after hospitalization. It was found that African American children had significantly fewer primary care visits than their white counterparts, even after adjusting for potential confounding variables. In contrast, emergency service utilization did not differ by race. The authors conclude that racial disparity exists in primary care access among children with asthma. Interventions should be designed to target poor African American children who suffer disproportionately from this life-threatening yet treatable disease.

Changes in positions of authority held by US physicians: a fresh look at existing data.

Some experts contend that physicians have lost positions of authority in the past 40 years. Others argue the opposite, yet neither side bases its arguments on empirical data. This study examined longitudinal variables measuring authority positions held by physicians. Data on the relative position of physicians in medical schools show that medical doctors held 65.6% of the sampled positions in 1970 vs 72.8% in 1990. Yet, in the wider society and within the nonmedical school portion of the health sector, other data indicate that physicians occupy a smaller proportion of authority positions.

Morbidity among pediatric motor vehicle crash victims: the effectiveness of seat belts.

It is well established that seat belts reduce mortality and morbidity among children. Data are presented for 413 children injured severely enough in motor vehicle crashes to require hospitalization. Of the unrestrained children, 4.5% died, compared with 2.4% of the belted children. Unrestrained children had a higher proportion of injuries in four of five anatomical regions, were more severely injured, stayed longer in the hospital, and were 15% more likely than belted children to be discharged with impairments.

Safety behavior of in-line skaters.

OBJECTIVES AND SETTING: Injuries from in-line skating have risen sharply in many cities around the world. To understand risk taking behavior and safety practices associated with urban in-line skating, 2210 outdoor skaters were observed in Boston, Massachusetts. METHODS: Estimated age, gender, use of helmets, wrist guards, elbow and kneepads were recorded. Skaters were coded as beginner, average, or advanced, and skating locations were classified as street, sidewalk, or bicycle path. RESULTS: About 60% of skaters wore wrist guards, but only 5.7% wore helmets. Males wore less protective equipment than females, and were more likely to skate on streets. Beginners and advanced skaters wore more protective gear than average skaters. Surprisingly, street skaters wore less protective gear than skaters on sidewalks or paths. CONCLUSIONS: Renewed focus on the importance of wearing helmets is needed. Given the higher injury risks for males, clinicians and public health experts need to target male skaters in prevention efforts. In addition, average and advanced skaters need to be convinced that even though they have improved, it is still important to wear protective gear.

Trauma-rehabilitation connections: discharge and admission decisions for children.

Paediatric discharge coordinators and rehabilitation admission coordinators were surveyed about how children are selected for rehabilitation. The following areas are covered: (1) the decision process, and how children are selected for rehabilitation; (2) who is involved in making acute-care discharge and rehabilitation admission decisions; (3) factors that guide selection of children for rehabilitation; and (4) satisfaction with referral practices. Surveys were completed by 30 trauma discharge and rehabilitation admission coordinators, recruited from paediatric trauma units and paediatric/general rehabilitation units nationwide. Most respondents were satisfied with transfers, although some voiced concerns about constraints placed on referrals by insurance. Even when inpatient rehabilitation was clearly needed, 40% said insurance status still affected whether children were admitted. There was little evidence that any uniform criteria are used to make decisions. Half had no training in discharge/admission planning and half did not base decisions on functional assessments. Although guidelines are increasingly used in clinical decision-making, few are available concerning critical decisions about which children receive inpatient rehabilitation following trauma.

Utilization of inpatient rehabilitation services among traumatically injured children discharged from pediatric trauma centers.

This paper investigates factors that predict whether or not children treated at pediatric trauma centers are discharged to inpatient rehabilitation. Variables pertaining to functional impairments, injury severity and institutional factors explained over 45% of the variance in discharge disposition. It appears that a good deal of rationality pervades the decision as to whether patients are discharged to home or to rehabilitation. The extent of functional impairments and the severity of injury are closely related to these discharge decisions, as one would expect in a well-functioning discharge planning system. However, there are indications that discharge decisions are also affected by factors that ideally should be external to the decision process. Chief among these is whether or not the trauma center has an onsite rehabilitation unit. Patients treated at trauma centers that have onsite rehabilitation units are significantly more likely to be discharged to rehabilitation than patients treated at trauma centers without onsite rehabilitation.

Admitting paediatric trauma patients to rehabilitation following acute care: decision making practices in the USA and Australia.

Paediatric patient access to rehabilitation services following trauma has significant long-term implications for clients, their families and the community. The aim of this research was to examine and compare the process by which patients are discharged from acute care and enter rehabilitation in the USA and Australia. The subjects were 31 American and 29 Australian discharge and rehabilitation admission coordinators. Subjects were surveyed about how they currently make trauma to rehabilitation referrals for children. Clinicians in both countries considered the severity of a child's injury and their social situation the most important factors when determining placement for a child. However, there were differences between Australian and US respondents in terms of how important they considered the factor 'medical coverage'. In addition, it was found that clinicians are not consistently using both standardized assessments and formal guidelines to assist them to determine which children should receive rehabilitation following acute care. Benefits of this research include a greater understanding of clinician discharge and admission decision making, and the equity of such decisions. However, further research is required on the influence of payment systems on access to paediatric rehabilitation.

Return to work after stroke: development of a predictive model.

Seventy-nine stroke patients who underwent a vocationally oriented, comprehensive, inpatient stroke rehabilitation program were followed up to evaluate their return to work. At follow-up, 49% had returned to work a mean of 3.1 months after rehabilitation discharge. Factors associated with success and with failure of vocational rehabilitation were then identified, and a predictive model was developed. There were positive associations between return to work and Barthel Index on admission (p = 0.0002) and discharge (p = 0.0015). Negative associations were found between return to work and aphasia (p = 0.0009), rehabilitation length of stay (p less than 0.0001), and prior alcohol consumption (p = 0.03). A step-wise multiple regression model explained 42% of the variance in return to work. Those most likely to return to work were not aphasic; they had shorter rehabilitation lengths of stay and higher Barthel Index scores on discharge; and they were lighter consumers of alcoholic beverages before their strokes. In conclusion, a set of factors predictive of return to work in younger stroke patients was identified, including, most notably, a strong negative association with aphasia and an intriguing negative association with prior alcohol consumption.

Ventilator dependency: decision-making, daily functioning and quality of life for patients with Duchenne muscular dystrophy.

Ventilator assistance is offered to patients with Duchenne muscular dystrophy as an option to extend life. This paper discusses the effect of respiratory difficulties and the subsequent quality of life for 17 patients and 14 family members living in the community. Areas covered included decision-making, health, education, vocational and recreational status, community resources and life satisfaction. Activity levels before and after ventilator use were assessed. Despite restrictions in daily life both before and after ventilator use, quality of life was fairly good. Restrictions in daily life were caused by a combination of progression of the disease and the ventilator, and family members were more burdened by the ventilator than were patients. It is concluded that patients and their families should make the decision about accepting or rejecting assisted ventilation.

Political implications of the 'new ageism'.

The research tradition of old age stereotypes has typically been limited to a social psychological perspective of their dysfunctional consequences. This exploratory study examines the possible functions served by such stereotypes from a sociocultural frame of reference, in particular, testing the hypothesis of Richard Kalish and Carroll Estes that problem-oriented conceptions of older persons are part of an emerging political ideology. Using the responses of the Louis-Harris-NOCA "The Myth and Reality of Aging in America" survey, the relation between aging stereotypes and attitudes toward federal support of the aged are reported.

Electrodiagnosis of diabetic peripheral polyneuropathy. A multivariate analytic approach.

Traditional univariate comparisons of nerve conduction data against standard norms may produce conflicting estimates of the presence or absence of a diabetic neuropathy, depending upon the data obtained and the specific nerves sampled. Alternatively, a multivariate analytic approach, using discriminant functions, provides a useful single measure of the degree of neuropathy determined as a weighted combination of the available data. The weights are derived from the linear discriminant function, which maximizes statistical separation of diabetic and nondiabetic subject groups. In this study, 12 electrophysiologic attributes are used to generate a single discriminant function that clearly separates diabetic from nondiabetic subjects and is interpretable as a neuropathic index. Each individual's index of diabetic neuropathy (I) can be quantified as follows: (Formula: see text) where Ai is the original electrophysiologic attribute (i = 12), ai is the coefficient for each attribute that defines the discriminant function and C is a constant specific for that function. For the first time, the degree of diabetic neuropathy can thus be quantified for purposes of comparison and correlation with other quantifiable clinical/somatic measures of diabetes. The index allows for a higher percentage of type II diabetic patients to be classified as neuropathic than previously described and enables determination of degree of neuropathy is affected individuals by an interpolative method.