Abraham B. Bergman

URBAN-RURAL LOCATION AND THE RISK OF DYING IN A PEDESTRIAN-VEHICLE COLLISION

Statewide data from two sources were used to compare the pedestrian-vehicle collision injury and fatality rates for urban and rural areas of Washington State from 1981 through 1983. Although the rates of pedestrian injuries are higher in urban areas, the pedestrian fatality rate in rural areas is higher for nearly all age groups, and at all posted speeds. Multiple logistic regression was carried out to measure the risk of dying once involved in a pedestrian-vehicle collision in rural areas compared to the risk for urban areas. This relative risk was seen to be elevated (RR = 2.3; 95% CI = 2.0-2.6) even after controlling for the effects of age and sex of the pedestrian, and posted speed of the vehicle. When explored further it was seen that a larger proportion of fatalities died out of the hospital and within the first hour after injury in rural areas than in urban areas. It is possible that Emergency Medical Services care is less rapidly available and that accessibility to trauma centers is more limited in rural areas.

The ineffectiveness of mechanically induced vomiting

Summary A case of herpes zoster with onset at 30 hours of age in a premature infant is presented. Recovery was uneventful and without apparent sequelae.

A Political History of the Indian Health Service

One of the few bright spots to emerge from the history of relations between American Indians and the federal government is the remarkable record of the Indian Health Service (IHS). The IHS has raised the health status of Indians to approximate that of most other Americans, a striking achievement in the light of the poverty and stark living conditions experienced by this population. The gains occurred in spite of chronically low funding and can be attributed to the combination of vision, stubbornness, and political savvy of the agencys physician directors and the support of a handful of tribal leaders and powerful allies in the Congress and the White House. Despite the agencys imperfections and the sizeable health problems that still exist among American Indians and Alaskan Natives, the IHS is an example of one federal program that has worked.

Evaluation of a community-based handgun safe-storage campaign.

Objective. Safe storage of firearms has been recommended as a means of preventing gun-related pediatric injuries, yet few interventions have led to significant improvements in storage practices. This study examined a multifaceted community education campaign to promote safe handgun storage and the campaigns impact on firearm locking and loading practices in households with children. Methods. Beginning in 1997, a safe-storage campaign consisting of television and radio announcements, educational materials, billboards, and discount coupons for lock boxes was conducted in King County, Washington. The campaign evaluation used a quasi-experimental design and compared the intervention site with 9 control counties outside Washington State and west of the Mississippi River. Cross-sectional, random-digit-dial telephone surveys of handgun-owning households with children were conducted in all study counties both before the intervention in 1996 (n = 302) and again in 2001 (n = 255). The main analyses assessed whether greater improvements in household firearm-storage practices occurred between 1996 and 2001 in the intervention, compared with the control, counties. Primary outcomes were based on up to 3 handguns per household and included (1) all stored with trigger locks, lock boxes, or gun safes (formal locking devices), (2) all stored in lock boxes or gun safes, (3) any stored loaded, (4) any stored loaded without a formal locking device, and (5) any stored loaded and not in a lock box or gun safe. Data were also collected on up to 1 long gun per household; long-gun outcomes included (1) stored with a trigger lock or gun safe and (2) stored loaded. Results. Overall, handguns and long guns were generally more likely to be stored locked and less likely to be loaded in 2001 compared with 1996, with these trends seeming to be more consistent in the intervention county. Even so, more than one quarter of households with children and handguns in 2001 failed to store all of their handguns with a formal locking device, and up to 8% continued to possess at least 1 loaded handgun that was not stored with a formal device. The majority of households that stored their handguns with formal devices used lock boxes or gun safes. Storage of handguns in lock boxes or gun safes became more common in both the intervention (adjusted odds ratio [aOR]: 1.71; 95% confidence interval [CI]: 1.03–2.84) and control households (aOR: 1.66; 95% CI: 1.01–2.72) between 1996 and 2001. None of the other measured changes reached statistical significance, such as storing any household handgun loaded (aOR: 0.71; 95% CI: 0.35–1.42 [intervention]; aOR: 1.08; 95% CI: 0.58–2.00 [control]) or keeping any household handgun loaded and not stored in a lock box or gun safe (aOR: 0.59; 95% CI: 0.22–1.55 [intervention]; aOR: 0.67; 95% CI: 0.30–1.49 [control]). Moreover, the intervention county did not experience significantly greater overall improvements in household storage practices for handguns or long guns than did control counties. Conclusions. In both the intervention and control counties, households were more likely to lock all handguns in 2001 compared with 1996. After accounting for temporal trends, this educational campaign, combined with economic incentives to purchase lock boxes, did not seem to significantly change safe storage practices in households with handguns and children. Even if the campaign did result in small improvements in firearm safe storage, simultaneous national and state-specific gun-safety activities or legislative efforts may have drawn increasing attention to gun-related issues in the control counties, thereby making it more difficult to identify effects of our specific handgun storage intervention.

Use of Education in Preventing Injuries

Health education, more than simply imparting information, should have some actual impact on death, disability, disease, discomfort, and dissatisfaction. The author calls for greater and more outreaching educational efforts to reach all those in society who possess the power to affect the environment in which children live.

The Sudden Death Syndrome of Infancy

The “crib death” that remains totally unexplained after complete necropsy is beginning to yield its secrets to careful follow-up study. Disclosing a surprisingly consistent pattern of pathologic and epidemiologic features, this research may open the way to eventual prophylaxis. It already provides physicians with the means to relieve parents of the dreadful burden of guilt many now carry.

Next steps in the study of sudden infant death syndrome

Varias licoes importantes podem ser aprendidas a partir do artigo de Pinho & Nunes1 presente nesta edicao. Primeiramente, em um cuidadoso estudo caso-controle, os autores mostram, de maneira convincente, que as caracteristicas epidemiologicas da sindrome da morte subita do lactente (SMSL) em Porto Alegre (RS) sao semelhantes as encontradas em outras partes do mundo onde mortes de lactentes ja foram estudadas. Essas caracteristicas incluem maiores taxas de prematuridade, baixo peso ao nascer, gravidez na adolescencia, etnia negra, tabagismo e pobreza – juntamente com a caracteristica mais distintiva e intrigante da SMSL, a saber, uma media de idade de 3 meses ao obito. Os autores apontam que, por causa da relativa prosperidade e diversidade da populacao de Porto Alegre, a incidencia determinada de 0,55/1.000 nascidos vivos pode nao ser representativa de outras areas do Brasil. Em areas menos prosperas, a frequencia dessa incidencia provavelmente e maior, assim como a mortalidade infantil em geral.

Sudden Death Syndrome The Physician's Role:

From the Childrens Orthopedic Hospital and Medical Center, and The Departments of Pediatrics, Preventive Medicine, and Pathology, University of Washington School of Medicine, Seattle, Washington

Pediatric Manpower Problems Are Solvable

Pediatric manpower problems can be approached logically only when pediatric care is viewed as a collection of skills and tasks, varying in complexity, rather than as numbers of bodies of health professionals. Health care tasks must be reallocated on the basis of how well they are performed rather than the number of academic diplomas possessed by the performer.

A Pediatrician’s Perspective on Child Protection

When the author started his pediatric residency in 1958, trauma inflicted on children had been described in the medical literature, mostly by radiologists, but its existence was not generally recognized by clinicians. Child maltreatment was initially viewed as a disorder of parenting. This meant that, in addition to investigative responsibilities, the new breed of case workers were charged with providing support. Mandatory reporting laws, along with professional and public awareness, soon swamped the protective services system; the supportive mission was not maintained. In the past decade, there has been a marked diminution in the prevalence of physical and sexual abuse; neglect now constitutes over 75% of the reported cases of maltreatment. The author maintains that children’s protective services have outlived their usefulness. Investigations of assaults should be conducted by law enforcement personnel, and suspected neglect should first be evaluated by public health nurses.